THE  LIBRARY 

OF 

THE  UNIVERSITY 
OF  CALIFORNIA 

LOS  ANGELES 


GIFT  OF 

SAN  FRANCISCO 
COUNTY  MEDICAL  SOCIETY 


ROENTGEN  TECHNIC 


ROENTGEN     TECHNIC 

(DIAGNOSTIC) 


BY 


NORMAN  C.  PRINCE,  M.D. 

ATTENDING   ROENTGENOLOGIST    TO    THE    OMAHA   FREE    DENTAL    DISPENSARY    FOR 
CHILDREN  ;    ASSOCIATE    ROENTGENOLOGIST    TO    THE    DOUGLAS    COUNTY 
HOSPITAL,    BISHOP    CLARKSON    MEMORIAL    HOSPITAL,    SWED- 
ISH   IMMANUEL     HOSPITAL,    ST.     JOSEPH'S     HOSPI- 
TAL,  AND  FORD    HOSPITAL,   OMAHA,    NEBR. 


WITH  SEVENTY-ONE  ORIGINAL  ILLUSTRATIONS 


ST.  LOUIS 
C.  V.  MOSBY  COMPANY 

1917 


COPYRIGHT,   1917,   BY  C.   V.    MOSBY   COMPANY 


Press  of 

C.   V.  Mosby  Company 
St.  Louis 


Biomedkal 
Library 

WN 


Ifit 

PEEFACE 

This  small  volume  has  been  prepared  particularly  for 
those  general  practitioners  who  have  seen  fit  to  install 
x-ray  equipments  along  with  the  numerous  other  appa- 
ratus necessary  in  helping  them  to  best  care  for  those 
who  come  under  their  observation.  There  has  been  very 
little  written  in  English,  dealing  exclusively  with  roent- 
gen  technic  and  it  has  seemed  to  the  author,  after  hav- 
ing talked  with  many  physicians,  that  such  a  publication 
is  sorely  needed. 

It  is  so  common  to  have  one's  attention  drawn  to  a 
case  where  a  physician  is  doing  so-called  gastrointestinal 
diagnosis  by  means  of  the  roentgen  ray,  his  entire  pro- 
ceeding consisting  of  an  opaque  meal  followed  by  one 
plate  taken  with  the  clothing  on,  that  one  is  led  to  be- 
lieve that  such  a  procedure  is  not  due  to  negligence  on 
the  part  of  the  physician,  nor  used  for  show  only,  but 
that  it  is  due  wholly  and  entirely  to  ignorance  —  the  phy- 
sician knowing  nothing  else  to  do.  One  also  is  brought 
face  to  face  every  day  with  the  man  who  is  taking  bone 
plates  one  way  only,  and  thereby  at  no  time  rendering  a 
diagnosis  of  any  value.  But  why  should  one  wonder  at 
these  gross  errors  when  one  takes  into  consideration  the 
preparation  given  the  neophyte  by  the  x-ray  salesman? 
His  machine  is  set  up,  a  few  plates  hurriedly  exposed  and 
developed,  all  of  which  looks  easy,  and  then  he  is  left  to 
his  own  resources.  The  consequence  is,  from  the  begin- 
ning he  is  working  in  the  dark,  never  knowing  the  winy 
and  the  wherefore  of  any  process. 

It  is  needless  to  say,  from  the  fact  that  this  book  deals 
exclusively  with  roentgen  technic  from  a  diagnostic 
standpoint,  that  nothing  has  been  said  regarding  inter- 
pretation. So  much  has  been  and  is  being  written  upon 


10  PREFACE 

this  branch  of  the  subject  by  the  masters  that  it  is  not 
for  me  to  touch  upon.  It  has  been  assumed  that  all  read- 
ers of  this  volume  are  using  interrupterless  transformers; 
the  coil,  therefore,  has  not  been  given  any  consideration, 
as  it  has  been  abandoned  almost  universally  for  the 
former  type  of  apparatus. 

The  author  wishes  to  express  his  gratitude  to  his  col- 
leagues, Doctors  Tyler  and  Kuegle,  for  information  and 
suggestions  tendered. 

N.  C.  P. 


CONTENTS 


CHAPTER  I. 

GENERAL   PRINCIPLES 


CHAPTER  II. 
X-RAY   TUBES      ....     ................       24 

,     CHAPTER  III. 
OPERATION  OF  MACHINE      ................      27 

CHAPTER  IV. 
GENERAL   EXAMINATION  ROUTINE     .............      31 

CHAPTER  V. 

POSITIONS   AND   EXPOSURES      ...............      39 

CHAPTER  VI. 

SINUS  INJECTION    ...................     103 

CHAPTER  VII. 

LOCATION  OF  FOREIGN  BODIES     ..............     104 

CHAPTER  VIII. 
DARK  ROOM  PROCEDURES     ........     ......     .     .     107 

11 


ILLUSTRATIONS 


FIG.  PAGE 

1.  Pathway  of  current  from  line  to  tube 22 

2.  Old   style    gas   tube 24 

3.  Coolidge   tube 25 

4.  Gas   tube   connected   to   transformer 29 

5.  The  advantage  of  taking  a  fracture  in  both  planes 32 

6.  A.    When  tube  is  centered  exactly  over  fracture.     B.     When  tilted 

to   one   side 33 

7.  Plate  changing  tunnels  for  stereoscopy 34 

8.  Tilting  side  of  Kelly  tube  stand 35 

9.  Shifting  side  of  Kelly  tube  stand 35 

10.  Change  in  position  of  tube  when  taking  stereoscopic  plates     ...  36 

11.  Set  of  Hickey  cones  and  diaphragms 37 

12.  Lead   markers  on   adhesive   strips 38 

13.  Anteroposterior   wrist   and   hand    position 41 

14.  Lateral  wrist  position 41 

15.  Anteroposterior  elbow  position 43 

16.  Lateral  elbow  position 43 

17.  Anteroposterior  ankle   position 45 

18.  Lateral  ankle  and  lateral  tarsus  positions 45 

19.  Lateral  ankle  and  lateral  tarsus  positions 47 

20.  Anteroposterior  tarsus   position 47 

21.  Anteroposterior    knee    position 49 

22.  Lateral   knee    position 49 

23.  Anteroposterior  hip  position 51 

24.  Anteroposterior  pelvis  position 53 

25.  Anteroposterior  shoulder  position 55 

26.  Lateral  cervical  spine  position 57 

27.  Anteroposterior   cervical  spine   position .     .  57 

28.  Anteroposterior  dorsal  spine  position 59 

29.  Oblique    dorsal    spine    position 59 

30.  Anteroposterior   lumbar   spine   position 61 

31.  Oblique  lumbar   spine  position 61 

32.  Clavicle    position 63 

33.  Scapula   position 65 

34.  Kidney    position 69 

35.  Bladder  position  on  dorsum 69 

36.  Kidney    position 72 

37.  Bladder  position  on  dorsum 73 

38.  Prone  bladder  position 73 

39.  Chest    position 77 

13 


14  ILLUSTRATIONS 


40.  Lateral  head  position 79 

41.  Inferosuperior    head    position 79 

42.  Anteroposterior  head  position 80 

43.  Mastoid  position 81 

44.  Mandible    position 83 

45.  Position  in  taking  upper  teeth 85 

46.  Position  in  taking  lower  teeth 85 

47.  Gall  bladder  position 87 

48.  Position    for    esophagus 89 

49.  Prone    stomach   position 92 

50.  Oblique    stomach    position 93 

51.  Standing   stomach  position 93 

52.  Showing  serial  plate  apparatus  ready  for  use 95 

53.  Showing  serial  plate  apparatus  tilted  upward  when  not  in  use     .  96 

54.  Diagram  showing  relative  distance  between  object  and  plate     .     .  105 

55.  Plate,  cassette  and  envelope  rack  shelf  in  dark  room 10S 

56.  Ventilating  shafts  in  dark  room  walls 109 

57.  A  print  drying  on  a  ferrotype  after  squeegeeing 120 

58.  Showing   camera  mounted   on   permanent   stand  for   lantern   slide 

making 122 

59.  Rear  of  camera  showing  centering  squares  on  ground   glass     .     .  123 

60.  Simple   method   of  arrangement    for  making   lantern    slides   from 

illustrations 124 

61.  A    negative        125 

62.  A  positive 126 

63.  Manner  in  which  envelopes  are  marked  for  filing 129 

64.  Case    record    book 130 

65.  Cross    index    card 132 

66.  Floor   plan   No.    1 135 

67.  Floor   plan    No.   2 135 

68  Floor    plan    No.    3 135 

69.  Floor   plan   No.   4 136 

70.  Floor   plan   No.   5 136 

71.  Floor   plan   No.    6 137 


ROENTGEN  TECHNIC 
(Diagnostic) 


ROENTGEN  TECHNIC 


CHAPTER  I 
GENERAL  PRINCIPLES 

X-rays  are  certain  rays  of  unknown  number  which  are 
produced  when  a  high  tension  current  is  forced  through 
a  specially  constructed  vacuum  tube.  These  rays  when 
produced  will  theoretically  penetrate  all  substances,  some 
with  greater  ease  than  others.  The  general  rule  is  that 
the  greater  the  atomic  weight,  the  less  the  ease  of  pene- 
tration. The  following  list  of  common  substances  is  given 
in  order  of  their  ease  of  penetrability: 

1.  Air. 

2.  Celluloid. 

3.  Aluminum. 

4.  Cardboard. 

5.  Wood. 

6.  Flesh. 

7.  Rubber. 

8.  Barium  or  bismuth. 

9.  Bone — teeth. 

10.  Steel. 

11.  Lead. 

When  centering  x-rays  on  an  object,  these  varying  de- 
grees of  penetration  take  place;  but  in  order  to  profit 
by  them,  there  must  be  some  way  whereby  they  may  be 
perceived.  Two  methods  have  been  devised ;  namely,  the 
fluorescent  screen  and  the  sensitized  plate. 

17 


18  ROENTGEN    TECHNIC 

The  Fluorescent  Screen 

The  fluorescent  screen  is  nothing  more  than  an  ordi- 
nary piece  of  cardboard  coated  with  a  combination  of 
chemicals  which  have  the  peculiar  property  of  fluorescing 
when  exposed  to  the  x-rays,  the  same  as  a  match  will 
fluoresce  in  the  dark  when  rubbed  between  moist  fingers. 
Of  course,  this  fluorescence  can  not  be  seen  except  in  dark- 
ness, and  then  only  when  the  pupils  of  the  eyes  have  di- 
lated to  their  fullest,  which  will  take  from  ten  to  twenty 
minutes.  When  the  rays  are  generated,  this  screen  will 
glow ;  and  when  the  excitation  of  the  tube  has  ceased,  it 
will  stop.  Some  makes  of  screens  have  what  is  known 
as  a  lag,  that  is,  fluorescence  continues  for  some  few  sec- 
onds after  the  discontinuance  of  the  energy  in  the  tube. 
Unless  the  operator  is  shifting  from  one  area  to  another 
very  rapidly,  this  will  have  no  detrimental  effect.  There 
are  also  two  distinct  colors  in  an  illuminated  screen,  one 
having  a  greenish  cast,  the  other  black  and  white.  One 
is  probably  as  good  as  the  other,  the  preference  depend- 
ing largely  upon  the  operator. 

If  the  tube  is  excited,  thereby  causing  the  screen  to 
fluoresce,  and  some  object  is  interposed  between  the  tube 
and  the  screen,  naturally  the  x-rays  do  not  reach  the 
screen  in  as  unhindered  a  state  as  they  do  when  no  object 
interferes;  therefore,  as  x-rays  to  all  practical  purposes 
only. travel  in  straight  lines,  the  portion  of  the  screen 
that  is  covered  by  the  interfering  object  will  not  fluoresce 
to  as  great  a  degree  as  the  areas  not  so  covered,  and  one 
is  thereby  enabled  to  discern  the  shape  of  the  object.  The 
fluorescence  will  be  hindered  directly  according  to  the 
difficulty  of  the  rays  in  passing  through  the  object.  As 
an  example,  if  a  number  of  objects,  say  a  hand  with  a 
bullet  supported  upon  the  palm,  is  interposed  between  an 
excited  tube  and  a  screen,  the  image  will  show  the  bullet 
practically  black,  as  no  rays  are  penetrating  it,  and  there- 


GENERAL  PRINCIPLES  19 

fore  the  screen  is  not  fluorescing  at  this  point.  Next,  the 
bones  are  seen  as  a  sort  of  a  grayish  black  because  some 
little  amount  of  the  rays  is  coming  through  and  causing  a 
slight  fluorescence.  Next,  the  flesh  is  seen  surrounding 
the  bones.  This  is  a  very  light  gray  color  because  a  large 
part  of  the  rays  is  coming  through  the  flesh  and  causing 
the  screen  to  light  up;  and  lastly,  the  air  surrounding 
the  hand  is  no  hindrance  to  the  rays,  and  the  entire  action 
is  thrown  on  the  screen  which  is  fully  illuminated. 

The  Sensitized  Plate 

The  sensitized  plate  or  film  is  briefly  a  piece  of  clear 
glass  or  celluloid  coated  with  certain  chemicals  in  a  gela- 
tine solution  which  has  been  allowed  to  dry  (dry  plate). 
The  coating,  film,  or  emulsion,  as  it  is  called,  is  prepared 
from  a  number  of  substances,  the  main  one  being  some 
salt  of  silver  which  is  mixed  with  liquid  gelatine;  and 
after  having  gone  through  a  process  of  heating  and  wash- 
ing, this  substance  is  ready  to  be  spread  very  thinly  and 
evenly  on  the  supporting  medium  and  set  away  to  dry. 
During  the  latter  part  of  the  process  of  preparation,  the 
emulsion  takes  on  a  property  whereby  if  it  is  exposed  to 
the  rays  of  the  solar  spectrum,  except  red,  and  then  put 
into  a  solution  of  certain  reducing  chemicals,  the  silver 
will  turn  black;  whereas  if  it  is  not  so  exposed  and  put 
into  the  solution,  it  will  remain  its  original  color,  a 
very  light  creamy  yellow.  All  the  rays  of  the  spectrum 
act  on  the  silver  except  red,  the  ultra-violet  probably  ex- 
erting the  greater  part  of  the  change. 

The  x-rays  possess  this  same  power,  and,  therefore, 
when  an  unexposed  plate  is  placed  near  an  excited  x-ray 
tube  and  then  put  into  the  developing  solution,  it  will  be 
found  to  have  undergone  the  change  and  will  turn  black 
instead  of  remaining  its  original  creamy  color.  Now,  if 
some  object,  say  a  bullet,  is  interposed  between  the  plate 


20 

and  the  tube,  it  is  easy  to  see  that  the  part  of  the  plate 
covered,  as  it  were,  by  the  bullet  will  not  receive  as  much, 
if  any,  of  the  rays  as  the  parts  not  so  covered.  The  sur- 
face so  covered  by  the  bullet  will  remain  creamy,  while 
the  surrounding  parts  that  get  the  full  effect  of  the  rays 
will  turn  black.  In  this  w^ay  it  is  possible  to  distinguish 
that  a  bullet  was  on  the  plate  at  the  time  of  exposure. 
Therefore,  if  the  same  illustration  is  taken  as  was  used 
for  the  fluorescent  screen,  the  same  end  is  accomplished, 
except  the  colors  are  reversed.  On  the  screen  it  was  seen 
that  the  bullet  remained  black  because  the  x-rays  could 
not  get  through  to  fluoresce  the  screen,  but  on  the  plate 
it  is  seen  that  the  bullet  remains  creamy  for  the  same 
reason,  the  rays  can  not  get  through  to  allow  the  silver  to 
be  acted  upon  and  it  therefore  remains  its  original  color. 
An  intensifying  screen  is  a  piece  of  cardboard  coated 
over  with  certain  chemicals  somewhat  the  same  as  a 
fluorescent  screen.  The  chemicals  used,  however,  are  dif- 
ferent so  that  one  can  not  be  used  satisfactorily  in  the 
other's  stead  as  has  been  tried  and  demonstrated.  This 
screen  is  very  sensitive  to  x-rays,  and  for  this  reason  is 
used  in  connection  with  plate  work  to  shorten  the  time 
of  exposure.  The  coated  side  of  the  screen  is  placed  in 
contact  with  the  film  side  of  the  plate,  either  in  a  spe- 
cially constructed  holder  for  this  purpose  called  a  cas- 
sette, or  in  the  ordinary  loading  envelope.  The  latter 
method  is  rarely  used,  as  the  surface  of  the  screen  is 
very  easily  marred,  and  if  scratched  or  splattered  with 
chemicals,  is  forever  useless,  these  defects  showing  on  all 
plates  subsequently  taken  with  it. 

If  the  minutest  quantity  of  rays  strikes  the  screen,  it 
will  act  by  lighting  up.  This,  in  turn,  affects  the  plate 
at  this  point  and  the  image  is  made.  Without  an  intensi- 
fying screen,  one  has  to  have  enough  rays  to  properly  af- 
fect the  silver  in  the  plate  to  make  the  desired  impres- 
sion. Intensifying  screens  seem  to  respond  particularly 


GENERAL  PRINCIPLES  21 

well  to  soft  rays,  therefore,  in  using  these  screens,  a  me- 
dium soft  tube  should  be  employed.  The  great  difficulty 
in  their  use  is  in  overexposing  the  plates.  The  latitude  of 
error  is  very  narrow;  the  plate  must  be  exposed  just  right 
or  a  poor  negative  will  result,  whereas,  with  the  plain 
plate,  a  slight  over-  or  underexposure  will  not  be  notice- 
able. 

For  producing  the  rays  to  reproduce  some  object  on  a 
sensitized  plate,  there  are  three  main  things  one  has  to 
take  into  consideration;  namely,  amount  of  voltage  used, 
number  of  milliamperes  of  current,  and  the  distance  from 
the  anode  of  the  tube  to  the  plate.  For  all  practical  pur- 
poses the  voltage  varies  from  55,000  to  70,000  and  the 
milliamperage  from  35  to  140.  It  is  roughly  estimated 
that  10,000  volts  will  span  a  gap  (air  space)  of  one  inch, 
therefore,  if  there  is  a  gap  of  5]/2  inches  which  the  cur- 
rent will  span,  but  no  farther,  it  can  be  assumed  that  the 
current  is  approximately  55,000  volts,  and  with  a  7  inch 
gap,  70,000  volts. 

In  the  positive  side  of  the  circuit  there  is  usually  set 
what  is  known  as  a  milliammeter,  a  gauge  for  register- 
ing the  number  of  milliamperes  (one-thousandth  part  of 
an  ampere)  passing  through  the  tube.  This  milliampere 
reading  depends,  if  a  gas  tube  is  used,  upon  the  degree 
of  vacuum  in  the  tube,  but  if  a  Coolidge  tube  is  employed/ 
a  different  principle  is  involved,  this  device  depending 
on  the  degree  of  heat  in  a  small  tungsten  filament  which 
is  placed  in  the  circuit  within  the  tube.  In  the  gas  bulb, 
the  greater  the  vacuum  the  lower  the  milliamperage,  and 
the  harder  the  tube.  In  the  Coolidge  tube,  the  greater 
the  heat  in  the  filament  the  more  electrons  are  set  free 
and  this  in  turn  allows  more  milliamperes  to  pass,  and 
we  therefore  have  a  softer  tube.  In  Fig.  1  a  schematic 
sketch  has  been  made  of  the  current  so  as  to  make  the 
course  in  the  production  of  x-rays  more  easily  understood. 

The  electrical  current  is  seen  to  travel  in  a  circle,  the 


22 


ROENTGEN   TECHNIC 


STEP- UP  TRANSFORMER 


SYNCHRONOUS  MOTOR 


Fig.    1. — Pathway   of   current   from   line   to   tube. 


GENERAL  PRINCIPLES  23 

outgoing  wire  being  the  positive  (  +  )  and  the  incoming, 
the  negative  ( — ).  It  accomplishes  its  work  while  travel- 
ing the  circle,  the  whole  thing  being  known  as  the  circuit. 
From  the  source  of  supply,  the  current  (alternating  as- 
sumed) is  taken  two  ways;  namely,  (a)  to  the  motor  and 
(b)  to  the  tube  via  the  transformer.  The  current  that 
goes  to  the  motor  does  not  enter  into  the  production  of 
the  x-rays,  but  is  simply  for  excitation  of  the  motor  which 
in  turn  causes  the  rectifying  wheel  or  switch  to  revolve. 
The  supply  or  incoming  current  is  small,  usually  220 
volts.  When  this  emerges  from  the  coil  or  transformer, 
it  has  been  raised  in  voltage,  or  "stepped  up"  as  it  is 
termed,  so  that  it  is  now  a  high  tension  current,  whereas 
before  this  raising  process  it  was  of  low  tension.  As  it 
flows  through  the  rapidly  revolving  rectifying  wheel  it  is 
changed  into  a  direct  current  which  is  necessary  for  the 
successful  operation  of  an  x-ray  tube.  If  the  current  is 
not  prevented,  it  will  flow  through  the  tube  and  back  to 
the  source,  thus  completing  the  circuit.  At  points  C  and 
D  (Fig.  4)  there  are  rods  so  arranged  that  their  ends  can 
be  placed  at  varying  distances  from  each  other.  If  these 
points  are  brought  very  close  together,  the  current  will 
take  this,  the  easiest  route,  not  going  around  by  the  way 
of  the  tube.  This  is  what  is  known  as  the  spark  gap. 


CHAPTER  II 

X-RAY  TUBES 

X-ray  tubes  are  of  two  general  classes;  namely,  gas 
tubes  and  Coolidge  tubes,  and  operate  upon  two  distinct 
principles. 

The  gas  tube  (Fig.  2)  is  a  glass  bulb  with  the  air  ex- 
hausted to  a  certain  point,  nearly  a  complete  vacuum. 


Fig.   2. — Old  style  gas  tube. 

It  is  equipped  with  a  regulating  chamber  so  that  a  small 
quantity  of  air  can  be  let  in  which  will,  of  course,  reduce 
the  vacuum.  With  such  a  tube  the  current  which  travels 
through  it  of  necessity  must  pass  through  this  partial 
vacuum.  It  has  been  determined  that  the  nearer  a  per- 
fect vacuum  in  a  tube,  the  harder  it  is  to  force  an  elec- 
trical current  through  it,  but  when  forced  through  a  high 
vacuum,  hard  rays  are  given  forth,  and  they  are  more 
penetrating  and  less  likely  to  burn  than  the  soft  ones. 

24 


'X-RAY  TUBES  25 

Conversely  the  less  perfect  the  vacuum  or  the  more  air 
in  the  tube,  the  easier  to  force  the  current  through, 
and  soft  rays  are  produced.  It  is  easy  to  see  that  if  the 
vacuum  or  resistance  in  the  tube  is  greater  than  the  spark 
gap  resistance,  the  current  will  take  the  easier  route  and 
jump  the  gap.  If  the  gap  is  now  increased  to  such  a 
point  that  the  current  will  pass  through  the  tube  in  pref- 
erence to  the  gap,  the  tube  is  said  to  be  backing  up  a 
parallel  spark  gap  of  so  many  inches.  If,  however,  it  is 
desired  that  the  tube  back  up  so  many  inches  and  no 
more,  just  enough  air  should  be  admitted  so  that  it  will 
not  jump  that  distance.  The  tube  is  then  as  desired. 


Fig.   3. — Coolidge  tube. 

The  Coolidge  tube  (Fig.  3)  is  operated  upon  an  entirely 
different  principle.  It  is  pumped  to  an  almost  perfect 
vacuum  which  remains  the  same  constantly.  At  the  neg- 
ative end  of  the  tube  is  a  small  tungsten  filament  within 
the  pumped  bulb.  This  is  lighted  by  means  of  an  at- 
tachment to  an  ordinary  light  socket.  It,  however,  will 
take  only  approximately  12  volts  so  that  the  current 
which  usually  is  of  110  volts  capacity  must  be  cut  down 
to  the  required  12  volts.  This  is  accomplished  by  a  small 


26 


ROENTGEN   TECHNIC 


apparatus  known  as  a  step-down  transformer.  The  in- 
tensity of  this  light  can  be  increased  or  diminished  at  the 
will  of  the  operator  by  means  of  a  little  instrument  known 
as  the  filament  control.  When  the  filament  is  burning  its 
maximum  of  current  or  is  at  its  brightest,  the  tube  will 
take  the  most  current,  the  same  as  would  the  gas  tube 
when  it  had  the  maximum  of  air  in  it.  In  either  instance 
the  tube  is  spoken  of  as  a  soft  tube.  Conversely  when  the 
filament  is  burning  low  or  as  in  the  case  of  a  gas  tube, 
when  the  air  is  at  its  lowest,  then  the  tube  is  hard. 

The  intensity  of  the  x-rays  is  in  inverse  proportion  to 
the  square  of  the  distance.  If  the  exposure  for  a  certain 
part  is  three  seconds  with  ten  inches  between  the  plate 
and  the  anode,  the  time  of  exposure  required  for  in- 
creased distances  will  be  as  follows: 


Distance 

Time 

in 
inches 

in 
seconds 

10 

a 

11 

3.63 

12 

4.32 

13 

5.07 

14 

5.88 

15 

6.75 

16 

7.68 

Distance 

in 
inches 

17 

18 
19 
20 
21 

22 
23 


Time 
in 

seconds 

8.67 
9.72 
10.83 
12 

13.23 
14.52 
15.87 


Distance 

in 
inches 

24 
25 
26 
27 
28 
29 
30 


Time 

in 
seconds 

17.28" 

18.75 

20.28 

21.87 

23.52 

25.23 

27. 


CHAPTER  III 


OPERATION  OF  MACHINE 

After  the  installation  of  the  equipment,  the  first  thing 
for  the  beginner  to  do  is  to  test  out  his  tubes  so  that 
he  may  know  what  setting  he  wants  when  different  parts 
come  up  for  roentgenographing.  First,  after  starting  the 
motor  (assuming  he  has  an  interrupterless  transformer) 
and  setting  the  polarity  switch  as  indicated,  he  lights  the 
filament  in  the  Coolidge  tube,  if  such  is  to  be  used,  set- 
ting the  control  at  a  point  about  one-half  way  of  the 
scale.  The  spark  gap  is  set  about  4y2  inches,  and  the 
rheostat  placed  on  about  the  20th  button  or  about  two- 
thirds  out.  The  final  or  x-ray  switch  is  now  closed  and  if 
the  gap  is  not  spanned  by  the  current,  the  control  is  re- 
duced or  sent  backwards  a  few  points  and  the  procedure 
repeated.  If  the  spark  jumps  the  gap  the  filament  light 
is  increased  and  so  on  until  such  a  point  is  reached  that 
the  current  is  such  that  it  will  constantly  spit  across  the 
gap,  the  milliamperage  being  noted.  If  it  is  in  the  neigh- 
borhood of  35,  let  it  stand.  If  lower,  increase  the  control 
button.  This  will  require  a  change  in  the  filament  again. 
By  manipulating  the  rheostat  and  the  control  button  of 
the  filament,  one  can  finally  get  an  output  that  will  re- 
cord a  certain  number  of  milliamperes  with  a  certain 
backup  spark.  When  once  35  milliamperes  backing  up 
514  inches  has  been  found,  note  it  on  paper.  Now  set 
tube  so  that  it  will  carry  75  milliamperes  with  a  6  inch 
gap  as  also  the  following: 

90  ma.  backing  up  a  6       inch  gap. 


40 

70 

100 

140 

60 


6% 
6% 

6V2 

6  ¥2 
4  ¥2 


27 


28  ROENTGEN   TECHNIC 

After  these  have  all  been  set  down  on  paper  one  will 
have  something  like  the  following: 

MILLIAMPERES    COOLIDGE  CONTROL    SPARK  GAP    RHEOSTAT  CONTROL  BUTTON 

60  4  13/20  4%  24 

35  4  3/20  51/2  22 

75  4  12/20  6  25 

90  4  8/20  6  26 

60  4  3/20  6^  25 

70  4  4/20  61/2  26 

100  4  6/20  6%  27 

140  4  4/20  6%  28 

The  gap  can  now  be  opened  to  its  fullest  capacity,  and 
unless  some  new  combination  is  to  be  used,  it  need  never 
be  closed  again,  for  with  a  given  Coolidge  tube,  one  will 
always  get  an  exact  duplication  if  the  same  formula  is 
followed.  If  a  gas  tube  is  used,  a  different  procedure  is 
employed.  The  rheostat  is  set  on  the  first  button  and  the 
spark  gap  placed  at  say,  6  inches.  The  x-ray  switch  is 
now  closed.  The  meter  will  probably  read  somewhere 
between  20  and  30  milliamperes.  Now  the  rheostat  can 
be  thrown  over  several  buttons  until  the  spark  gap  is 
spanned.  It  is  then  reduced  one  button  and  the  milli- 
amperage  noted.  If  this  is  too  hard  a  tube,  it  can  be  low- 
ered by  sending  a  small  amount  of  current  through  the 
regulating  chamber.  This  is  accomplished  either  by  con- 
necting the  chamber  to  a  cord  connected  to  a  movable 
reel  placed  on  the  front  of  the  transformer,  the  reel  being 
capable  of  being  drawn  close  to  the  negative  post;  or  by 
means  of  a  stiff  wire  attached  to  the  chamber,  the  end 
of  which  can  be  brought  in  close  proximity  to  the  nega- 
tive end.  (Fig.  4.)  The  current  normally  goes  from  A 
to  B  directly  through  the  tube.  If  the  tube  is  to  be  re- 
duced or  softened,  cord  F  is  connected  to  the  regulating 
chamber  at  G,  and  E  is  brought  close  to  D,  which  is  done 
by  tension  on  a  string.  The  rheostat  is  put  on  the  first 
button  and  the  final  switch  is  closed.  This  sends  the  cur- 
rent through  the  regulating  chamber  G  back  to  D  in- 
stead of  through  B.  Sometimes  a  wire  is  used  from  G 


OPERATION    OF    MACHINE 


29 


to  B.  The  current  then  passes  from  A  to  B  via  G  instead 
of  A  to  B.  When  the  wire  is  not  in  use,  it  is  tilted  up- 
wards so  that  it  will  not  get  in  the  circuit.  When  gas 
tubes  are  to  be  used,  several  should  be  employed,  each 
having  a  different  backup  gap  as  it  is  not  only  very  an- 
noying but  soon  ruins  a  gas  tube  to  be  continually  chang- 
ing its  vacuum. 

When  using  the  fluoroscope,  usually  about  2  ma.  are 
employed,  the  penetration  being  regulated  by  the  fila- 


Fig.  4. — Gas  tube  connected  to  transformer. 

ment  when  using  the  Coolidge  or  by  the  third  wire  with 
the  gas  tube.  On  all  the  latest  fluoroscopes  there  is  a 
little  device  whereby  the  operator  can  control  the  gas 
tube  in  the  apparatus  simply  by  pulling  a  string  the 
same  as  on  the  transformer  when  regulating  for  picture 
work.  This  approximates  the  wire  connected  to  the  reg- 
ulating chamber  and  the  negative  post,  thereby  reduc- 
ing the  tube.  As  soon  as  the  tube  is  reduced  sufficiently, 
the  string  is  released  and  the  two  points  fly  apart.  This 


30  ROENTGEN   TECHNIC 

can  be  done  while  the  machine  is  in  operation  as  the 
milliamperage  is  so  low  (2  ma.)  that  the  reduction  is 
more  or  less  gradual.  If  this  were  done  with  a  roent- 
genographic  tube  running  with,  say  40  ma.,  the  reduction 
L  would  be  so  rapid  even  in  a  fractional  part  of  a  sec- 
ond that  the  tube  would  be  worthless  from  over  reduc- 
tion. It  would  be  so  soft  that  it  would  have  no  penetra- 
tion. 


CHAPTER  IV 

GENERAL  EXAMINATION  ROUTINE 

When  a  patient  is  submitted  for  x-ray  examination, 
first  take  a  complete  history.  The  following  is  a  good 
general  chart: 

No. Name 

Address 

Past  history, 

Present  sickness  or  accident, 

Physical  findings, 
Clinical  diagnosis, 

Eoentgenological  diagnosis,   

Date, Charge, 

Size  plate, Referred  by, 


This  is  made  a  convenient  size  to  file  alphabetically. 
After  the  history  is  taken,  the  patient  goes  to  the  dress- 
ing room  and  bares  the  part  to  be  examined.  If  a  spinal, 
gastrointestinal,  chest,  or  genitourinary  examination  is 
to  be  made,  all  the  clothing  is  removed,  and  if  a  female, 
a  white  washable  gown  is  slipped  on.  The  patient  is 
then  placed  on  the  table  and  a  complete  physical  exam- 
ination is  made,  all  points  being  noted  on  the  chart.  The 
x-ray  examination  is  then  proceeded  with. 

In  the  taking  of  any  roentgenogram,  there  are  three 
things  that  must  always  be  remembered;  namely, 

1.  Have  the  tube  centered  as  nearly  over  the  lesion 
as  possible. 

2.  Place  the  part  to  be  taken  as  near  the  plate  as  is 
convenient. 

3.  Have  the  rays  strike  the  plate  at  right  angles  un- 
less the  part  can  be  shown  to  better  advantage  otherwise, 

31 


32 


ROENTGEN   TECHNIC 


and  the  accompanying  distortion  does  not  make  any  ma- 
terial difference. 

Taking  these  up  in  their  order,  (1)  it  will  be  seen  in 
the  accompanying  illustration  that  -it  is  possible  to  make, 
for  instance,  a  fracture  appear  different  from  what  it 
really  is  by  not  being  particular  in  this  regard  (Fig.  6). 


Fig.   5. — The  advantage  of  taking  a  fracture  in  both  planes. 


GENERAL    EXAMINATION    ROUTINE 


33 


A  B 

Fig.  6. — A.  When  tube  is  centered  exactly  over  fracture.     B.   When  tilted  to  one  side. 


34  EOEXTGEX   TECHNIC 

(2)  The  nearer  an  object  is  to  the  plate  the  clearer  it 
will  appear  and  the  nearer  to  its  normal  size,  whereas, 
if  removed  to  any  considerable  distance,  it  Avill  appear 
hazy  and  very  much  magnified.  (3)  If  the  tube  is  not 
placed  so  that  the  rays  strike  the  plate  at  right  angles, 
overlying  parts  will  be  thrown  out  of  their  true  rela- 
tionship and  other  parts  will  be  distorted  as  to  their 
size  and  shape. 

In  all  extremity  work,  views  should  be  taken  in  two 
directions,  that  is,  anteroposteriorly  and  laterally.  If 
this  is  not  done  very  faulty  diagnoses  may  be  made.  A 
transverse  fracture  with  the  lower  fragment  lying  pos- 
teriorly to  the  upper,  will  in  a  large  majority  of  cases 


Fig.    7. — Plate   changing   tunnels   for   stereoscopy. 

not  show  the  misplacement  if  taken  anteroposteriorly, 
but  if  a  plate  is  taken  laterally,  the  faulty  position  will 
be  easily  seen.  (Fig.  5.)  Two  plates  are  not  only  more 
expensive  but  are  not  so  convenient  to  handle  as  one,  and 
therefore  a  single  plate  large  enough  to  take  in  both 
views  is  used,  the  half  not  under  exposure  being  cov- 
ered by  a  sheet  of  1/16  inch  lead.  A  pencil  mark  should 
be  made  on  the  envelope  where  the  lead  stops  so  that  one 
may  know  where  to  edge  it  when  making  the  other  ex- 
posure. If  it  is  impossible  to  get  a  lateral  view  of  a 
part  as,  for  instance,  the  shoulder  and  hip,  the  stereo- 
scopic method  should  be  employed.  This  is  accomplished 
by  the  use  of  twTo  plates  and  by  shifting  the  tube.  A 
thin  box,  the  proper  size  to  hold  the  covered  plate,  is 
placed  under  the  part  (Fig.  7)  and  the  patient  instructed 


GEXERAL    EXAMINATION    ROUTINE 


35 


Fig.   8. — Tilting  side   of  Kelly   tube  stand. 


Fig.  9. — Shifting  side  of  Kelly  tube  stand. 


36 


ROENTGEN    TECHNIC 


that  two  plates  are  about  to  be  taken  and  not  to  move 
until  the  sign  is  given.  The  tube  is  centered  exactly 
over  the  part  to  be  taken  and  by  a  special  device  on  all 
stands  locked  at  this  point,  the  tube  is  allowed  to  move 


Fig.   10. — Change  in  position  of  tube  when  taking  stereoscopic  plates. 


GENERAL    EXAMINATION    ROUTINE 


37 


both  ways  one  and  one-quarter  inches.  This  21/2  inches, 
as  will  be  seen  later,  is  the  approximate  distance  between 
the  two  pupils  of  the  eyes.  It  is  also  necessary  to  tilt 
the  tube  by  a  special  tilting  device  so  that  the  direct 
rays  are  at  both  extremes  pointing  to  the  center.  (See 
Figs.  8  and  9.) 

A  plate  is  slipped  into  the  box  and  tube  placed  in  posi- 
tion A  (Fig.  10)  and  the  exposure  made.  This  plate  is 
then  removed  and  placed  in  a  safe  place  and  another 
slipped  into  the  box  in  the  same  relative  position,  all  this 


Fig.  11. — Set  of  Hickey  cones  and  diaphragms. 

time  the  patient  should  remain  absolutely  quiet.  The 
tube  is  now  shifted  to  position  B  and  the  exposure  made, 
both  plates  having  the  same  time.  When  taking  the 
plates  to  the  dark  room,  number  them  No.  1  and  No.  2 
in  the  order  they  were  exposed.  This  will  be  found  use- 
ful when  placing  them  in  the  stereoscope.  If  No.  1  is 
placed  on  the  left  side  and  No.  2  on  the  right,  the  stereo- 
scopic effect  will  be  obtained  almost  at  once.  The  chang- 
ing boxes  should  be  four  in  number.  Two  capable  of 
holding  8  by  10  inch  envelopes  and  two  for  the  11  by  14 
inch  size;  one  of  each  size  having  the  opening  on  the 


38 


ROENTGEN   TECH  NIC 


end  and  the  other  on  the  side.  They  are  made  of  wood, 
the  top  being  of  either  celluloid,  aluminum,  cardboard, 
or  thin  wood,  all  of  which  offer  little  resistance  to  the 
rays.  If  wood  is  used,  it  should  be  free  from  knots  and 
as  thin  as  consistent  with  the  weight  that  is  put  upon 
it.  One  small  point  that  is  well  to  remember  with  this 


Fig.   12. — Lead  markers  on  adhesive  strips. 

stereoscopic  work  is  that  the  black  and  orange  envelopes 
in  which  the  plates  are  enclosed  are  always  somew^hat 
larger  than  the  plate.  This  is  done,  of  course,  to  facili- 
tate loading  them.  When  placing  the  two  plates  in  the 
box,  they  should  be  shaken  into  one  corner  or  the  other 
and  placed  in  corresponding  positions  at  each  exposure. 
It  makes  no  difference  which  corner  just  so  they  occupy 
the  same  in  the  box. 


CHAPTER  V 

POSITIONS  AND  EXPOSURES 

All  of  the  following  exposure  times  are  given  for  reg- 
ular Paragon  or  Seed  plates  and  Cramer  plates.  If  Cra- 
mer's are  used  with  the  teclmic  calling  for  Paragon  or 
Seed's,  increase  the  time  25  per  cent  as  the  former  are 
about  that  much  slower.  Detail  in  all  will  be  about  the 
same.  If  an  intensifying  screen  is  to  be  used,  divide  the 
time  given  about  one-eighth.  Intensifying  screens  do 
not  act  well  with  regular  Paragon  plates.  If  it  is  de- 
sired to  use  this  make  with  screens,  get  the  "screen" 
plate,  which  is  made  especially  for  this  class  of  work. 
Cramer's  and  Seed's  plates  seem  to  work  as  well  with  or 
without,  the  time  being  shortened  as  above  stated. 

In  the  following  list  of  exposure  times,  two  technics 
are  used  in  some  instances.  It  might  be  well  to  try 
them  both  out,  selecting  that  which  seems  to  give  the 
best  plates.  Some  prefer  the  one  while  some  like  the 
other.  With  the  first,  it  is  noticed  that  Paragon  or 
Seed's  are  used  and  Avith  the  second,  Cramer's.  All 
times  are  given  on  a  basis  of  an  adult  about  5  feet  10 
inches  tall  and  weighing  about  160  pounds.  Give  a  little 
more  or  less  according  to  weight.  Recently  a  new  plate 
has  been  placed  upon  the  market  (Diagnostic).  This  the 
author  has  found  to  be  very  fast,  having  four  times  the 
speed  of  the  Cramer  and  twice  that  of  the  Paragon  when 
used  directly.  "With  a  screen  its  speed  is  not  so  marked. 


39 


40 


ROENTGEX  TECHNIC 


Part. — Hand  and  Wrist 


Size  of  Plate. 

Diaphragm. 

Position. 

Name  of  Plate. 
Number  of  Exposures. 

Spark  Gap. 
Milliamperage. 
Distance. 
Time. 


8x10,  or  6^x8%. 

Large. 

Center     over    part     de- 

sired. 

Paragon  or  Seed  's. 

Cramer  's. 

Two.     Anteroposterior 

Two.     Anteroposterior 

and  lateral. 

and  lateral. 

5^  inches. 

4%  inches. 

35  ma. 

60  ma. 

18  inches. 

22  inches. 

Anteroposterior   i£   sec- 

Anteroposterior l1/^  sec- 

ond,   lateral    %    sec- 

onds,   lateral    2    sec- 

ond. 

onds. 

POSITIONS  AND   EXPOSURES 


41 


Fig.    13. — Anteroposterior  wrist  and   hand  pos:tion. 


Fig.    14. — Lateral   wrist  position. 


42 


ROENTGEN   TECHXIC 


Size  of  Plate. 

Diaphragm. 

Position. 

Name  of  Plate. 
Number  of  Exposures. 

Spark  Gap. 
Milliamperage. 
Distance. 
Time. 


Part. — Elbow 

8x10. 

Large. 

Center  between  con- 
dyles. 

Paragon  or  Seed's. 

Two.  Anteroposterior 
and  lateral. 

51/2   inches. 

35  ma. 

18  inches. 

Anteroposterior,  %  sec- 
ond; lateral,  %  sec- 
ond. 


Cramer 's. 

Anteroposterior  and  lat- 
eral. 

4%  inches. 

60  ma. 

22  inches. 

Anteroposterior,  3  sec- 
onds; lateral,  2%  sec- 
onds. 


POSITIONS   AND   EXPOSURES 


43 


Fig.    15. — Anteroposterior   elbow   position. 


Fig.    16. — Lateral   elbow   position. 


44 


ROENTGEN   TECHNIC 


Size  of  Plate. 
Diaphragm. 
Position. 
Name  of  Plate. 
Number  of  Exposures. 

Spark  Gap. 
Milliamperage. 
Distance. 
Time. 


Part. — Ankle 

8x10. 

Large. 

Through  malleoli. 

Paragon  or  Seed's. 

Two.      Anteroposterior, 

and  lateral. 
5%  inches. 
35  ma. 
18  inches. 
Anteropos  t  e  r  i  o  r,  1% 

seconds ;      lateral,     1 

second. 


Cramer 's. 

Two.       Anteroposterior, 

.  and  lateral. 
4i£  inches. 
60  ma. 
22  inches. 

Anteroposterior,  3  sec- 
onds; lateral,  2%  sec- 
onds. 


POSITIONS   AND   EXPOSURES 


45 


Fig.    17. — Anteroposterior   ankle   position. 


Fig.    18. — Lateral  ankle  and  lateral  tarsus  positions. 


46  ROENTGEN   TECHNIC 


Part. — Foot 

Size  of  Plate.     8x10.     (3) 

Diaphragm.     Large. 

Position.  First  a  stereoscopic  set  should  be  taken  with  the  foot  on  its 
external  side.  This  should  take  in  all  the  foot  and  ankle  joint. 
One  plate  (8x10)  should  now  be  taken  anteroposteriorly,  the 
patient  lying  on  the  back  with  the  knee  drawn  up  so  that  the 
plantar  surface  is  resting  firmly  on  the  plate.  The  tube  should 
now  be  brought  down  so  that  the  principle  rays  are  centered 
over  the  tarsus,  tilting  the  tube  so  that  the  rays  point  a  little 
toward  the  heel.  In  order  to  bring  out  the  tarsus  well  in  this 
position,  the  toes  will  have  to  be  somewhat  overexposed.  If  only 
the  toes  or  metatarsal  bones  are  desired,  the  exposure  will  nec- 
essarily be  somewhat  shorter.  (Figs.  19  a?id  20.) 

Name  of  Plate.  Paragon  or  Seed 's.  Cramer 's. 

Number  of  Exposures.       Three.  Three. 

Spark  Gap.  5[/^  inches.  4*6  inches. 

Milliamperage.  35  ma.  60  ma. 

Distance.  18  inches.  22  inches. 

Time.  Anteropost  e  r  i  o  r,  1%  Anteroposterior,  ?>  sec- 
seconds  ;  lateral,  1  onds ;  lateral,  2  sec- 
second,  onds. 


POSITIONS   AND   EXPOSURES 


47 


Fig.  19. — Lateral  ankle  and  lateral  tarsus  positions. 


Fig.    20. — Anteroposterior    tarsus   position. 


48  ROENTGEN   TECHNIC 


Part. — Knee 

Size  of  Plate.     10x12. 

Diaphragm.     Large. 

Position.  Place  patient  on  back,  with  the  center  of  the  plate  at  a  point 
about  2  inches  below  the  patella  (Fig.  21)  ;  also  one  exposure 
with  patient  lying  on  affected  side  with  plate  centered  over 
same  point  (Fig.  22). 

Name  of  Plate.                  Paragon  or  Seed's.  Cramer's 

Number  of  Exposures.       Two.  Two. 

Spark  Gap.                          5^j  inches.  4%  inches. 

Milliamperage.                    35  ma.  60  ma. 

Distance.                               18  inches.  22  inches. 

Time.  Anteropos  terior,  1%  Anteroposterior,  3  sec- 
seconds;  lateral,  1%  onds;  lateral,  2^  sec- 
seconds,  onds. 


POSITIONS  AND   EXPOSURES 


49 


Fig.  21.— Anteroposterior  knee  position. 


Fig.    22. — Lateral    knee   position. 


50 


ROENTGEN   TECHNIC 


Part. — Hip 

Size  of  Plate.     8x10. 

Diaphragm.     Large  with  cone. 

.Position.  Place  tip  of  thumb  over  highest  point  of  iliac  crest,  tip  of  mid- 
dle finger  over  great  trochanter  and  with  the  tip  of  the  first 
finger  form  a  triangle.  At  this  point,  center  the  principal  rays. 
Bring  the  cone  in  contact  with  the  skin  without  compression. 
.  (Fig.  23.) 


Name  of  Plate. 
Number  of  Exposures. 
Spark  Gap. 

Milliamp  erage. 

Distance. 

Time. 


Paragon  or  Seed 's. 
Two.     Stereoscopical. 
6     inches      (without 

screen). 
90      ma.      (without 

screen). 
Contact,  or  as  near  20 

inches  as  possible. 
1     second     (without 
screen). 


Cramer 's. 

Two.     Stereoscopical. 

4ty     inches     (with 

screen). 
60    ma.    (with    screen). 

Contact,  or  as  near  20 

inches  as  possible. 
3  seconds  (with  screen). 


POSITIONS  AND   EXPOSURES 


51 


Fig.   23. — Anteroposterior  hip  position. 


52 


ROENTGEN   TECHNIC 


Part. — Pelvis 

Size  of  Plate.     11x14. 

Diaphragm.     Large  or  none  (see  below). 

Position.  The  patient  is  placed  on  the  back  with  the  plate  extending  cross- 
wise at  the  point  midway  from  the  upper  and  lower  edge  site  of 
the  femoral  head,  as  shown  in  Fig.  24.  (To  find  the  femoral 
head,  place  the  tip  of  the  thumb  on  the  highest  point  of  the 
iliac  crest,  the  tip  of  the  middle  finger  on  the  greater  trochanter 
and  with  the  tip  of  the  index  finger,  form  a  triangle,  the  point 
over  which  the  index  finger  rests  is  the  approximate  site  of  the 
femoral  head.) 


of  Plate. 
X umber  of  Exposures. 
Spark  Gap. 

Milliamperage. 
Distance. 


Time. 


Paragon,  or  Seed's. 

Two.     Btereoseopical. 

6  inches  (without 
screen). 

90  ma.  (w  i  t  h  o  u  t 
screen). 

20  inches.  (If  a  dia- 
phragm is  used,  the 
distance  will  have  to 
be  increased  to  27 
inches.) 

1  second  at  20  inches 
without  screen,  or 
1  %o  seconds  at  27 
inches  without  screen. 


Cramer 's. 

Two.     Stereoscopical. 

4%     inches     (with 

screen). 
60  ma.  (with  screen). 

20  inches.  (If  a  dia- 
phragm is  used,  the 
distance  will  have  to 
be  increased  to  27 
inches.) 

3  seconds  with  screen 
at  20  inches,  or  5^ 
seconds  with  screen  at 
27  inches. 


POSITIONS  AXD   EXPOSURES 


53 


Fig.    24. — Anteroposterior   pelvis   position. 


ROENTGEX  TECHNIC 


Part. —  Shoulder 

Size  of  Plate.     8x10.      (Two  stereoscopical.) 

Diaphragm.     Large. 

Position.  Center  rays  a  little  internal  and  slightly  above  axilla  (Fig.  25). 
This  examination  should  always  be  made  stereoscopically,  as  it 
is  impossible  to  get  two  way  plates  satisfactorily.  The  stereo- 
scopic box  or  plate  holder  is  placed  under  the  affected  shoulder 
and  a  book  or  other  object  about  twice  the  thickness  of  the 
box  is  placed  under  the  opposite  side.  This  throws  the  shoulder 
to  be  taken  well  down  on  the  holder,  thereby  insuring  good 
detail. 

Name  of  Plate.  Paragon   or   Seed 's.  Cramer 's. 

Number  of  Exposures.  Two.  Two. 

Spark  Gap.  5ty  inches.  4%  inches. 

Milliamperage.  35  ma.  60   ma. 

Distance.  18  inches.  22  inches.    * 

Time.  2^>  seconds.  4  seconds. 


POSITIONS  AND   EXPOSURES 


55 


Fig.   25. — Anteroposterior  shoulder  position. 


56  ROENTGEN    TECHNIC 


Part. — Neck 

Size  of  Plate.     5x7.   (2)     8x10.   (1) 

Diaphragm.     Large  and  medium. 

Position.  A  lateral  view  should  first  be  taken.  This  is  best  done  by 
having  the  patient  sit  in  a  chair  with  the  tube  tilted  on  its  side 
(Fig.  26).  Use  the  medium  size  Hickey  cone,  allowing  it  to 
rest  on  the  patient's  shoulder.  In  fact  it  should  exert  some 
pressure  so  that  the  shoulder  is  forced  downward  as  far  as 
possible.  The  plate  (5x7)  is  held  by  an  assistant  against 
the  opposite  side  of  the  neck,  pressing  it  well  down  onto  the 
shoulder,  but  at  the  same  time  not  getting  it  too  far  from 
the  neck.  The  patient  is  asked  to  sit  in  an  attitude  of  dejec- 
tion with  shoulders  drooped  to  their  fullest  extent.  Unless  this 
is  done,  the  seventh  cervical  will  not  be  reached.  This  plate 
shows  the  lateral  view  of  all  the  cervicals. 

In  the  anteroposterior  position,  the  patient  should  be  lying 
on  the  flat  of  the  back,  the  head  just  off  the  table  (see  Fig. 
27).  An  8x10  plate  is  placed  under  the  neck,  extending  up  to 
the  occipital  protuberance.  The  rays  are  directed  about  2 
inches  above  the  episternal  notch.  This  will  take  in  all  the 
cervical  vertebrae  except  the  upper  two  or  three. 

The  third  position  is  to  obtain  these  upper  two  or  three  bones 
from  an  anteroposterior  view.  The  patient  is  on  the  back  with 
the  head  resting  on  the  table.  The  plate  (5x7)  is  placed  well 
up  under  the  occiput.  The  mouth  is  opened  to  its  fullest  extent 
(about  two  inches),  and  a  cork  placed  between  the  teeth.  The 
small  diaphragm  is  used,  the  rays  being  centered  over  the  open 
mouth.  This  plate  will  show  the  first  and  second  vertebra*  very 
plainly. 

Name  of  Plate.  Paragon  or  Seed's.  Cramer's. 

Number  of  Exposures.  Three.  Two  anteropos-  Three.  Two  anteropos- 
terior; one  lateral.  terior,  one  lateral. 

Spark  Gap.  5%  inches.  4%  inches. 

Milliamperage.  35  ma.  60  ma. 

Distance.  18  inches.  22  inches. 

Time.  Anteroposterior,  ?>  sec-  Anteroposterior,  4  sec- 

onds; lateral,  2%  sec-  onds;  lateral,  3l/2  sec- 

onds, onds. 


POSITIONS  AND   EXPOSURES 


57 


Fig.    26. — Lateral    cervical    spine   position. 


Fig.  27. — Anteroposterior  cervical  spine  position. 


58 


ROENTGEN   TECHNIC 


Part. — Dorsal  Spine 

Size  of  Plate.     11x14.     (3) 

Dia-phragm.     Large. 

Position.  The  upper  end  of  the  plate  should  be  on  a  level  with  the  seventh 
cervical  running  lengthwise  down  the  spine  with  the  body  cen- 
tered on  it  evenly  from  side  to  side.  The  principal  rays  should 
be  directed  over  its  center.  This  gives  an  aiiteroposterior  view 
of  the  whole  dorsal  region  (Fig.  28).  For  an  oblique  view,  lay 
the  patient  on  the  face,  rotating  him  a  quarter  turn  upward 
one  side  or  the  other,  placing  the  plate  a  little  posterior  from 
the  center  of  the  body  (Fig.  29).  Raise  the  arms  strongly 
above  the  head.  It  relieves  the  strain  somewhat  to  support 
the  raised  hip  and  shoulder  by  means  of  sand  bags.  If  the 
true  lateral  posture  is  desired,  the  patient  is  laid  squarely  on 
the  side  with  the  arms  extended  well  above  the  head.  The  plate 
is  placed  in  position,  remembering  that  the  spine  occupies  a 
point  about  two-thirds  back  from  the  chest  wall  in  front.  In 
all  these  exposures  it  should  be  remembered  that  the  patient 
should  be  directed  to  take  a  deep  breath  and  maintain  it  dur- 
ing the  time  of  exposure. 

Paragon  or  Seed 's. 

Three. 

5%  inches. 

35  ma. 

Anteroposterior,  36  in- 
ches; oblique  and  lat- 
eral, 30  inches. 

Anteroposterior,  10  sec- 
onds; oblique,  9  sec- 
onds; and  lateral,  9 
seconds. 


Name  of  Plate. 
Number  of  Exposures. 
Spark  Gap. 
Milliamperage. 
Distance. 


Time. 


Cramer's  (with  screen). 

Three. 

4i£  inches. 

60  ma. 

Anteroposterior,  36  in- 
ches; oblique  and  lat- 
eral, 30  inches. 

Anteroposterior,  6  sec- 
onds ;  oblique,  5  sec- 
onds; lateral,  5  sec- 
onds. 


POSITIONS  AND  EXPOSURES 


59 


Fig.   28. — Anteroposterior  dorsal   spine  position. 


Fig.   29. — Oblique  dorsal  spine  position. 


60  ROENTGEN    TEC  H  NIC 


Part. — Lumbar  Spine 

Sise  of  Plate.     11x14.     (2) 

Diaphragm.     Large  with  large  size  Hickey  compression  cone. 

Position.  Place  the  patient  on  the  back  with  the  plate  well  up  to  the 
mammillary  line  (Fig.  30).  The  cone  is  centered  over  the  epi- 
gastrium having  the  upper  edge  just  overlapping  the  costal  arch. 
Compression  is  now  made  at  the  same  time,  tilting  the  tube  so 
that  the  cone  fits  snugly  into  the  epigastrium.  The  patient  is 
instructed  to  take  a  full  breath  and  hold  it  until  the  exposure 
is  completed.  The  oblique  view  is  made  the  same  as  in  the  dorsal 
spine,  except  that  the  plate  and  tube  are  moved  downward  so 
as  to  take  in  the  lumbar  vertebrae  instead  of  the  dorsal  (Fig. 
31).  (See  dorsal  spine  technic.) 

Name  of  Plate.  Paragon  or  Seed's.  Cramer's. 

Number  of  Exposures.       Two.  Two. 

Spark  Gap.  5%  inches.  4^  inches. 

Milliamperage.  35  ma.  60  ma. 

Distance.  Contact  (about  18  inch-  22  inches. 

es). 

Time.  5   seconds     (without  3  seconds  (with  screen). 

screen). 


POSITIONS  AND  EXPOSURES 


61 


Fig.    30. — Anteroposterior   lumbar   spine   position. 


Fig.    31. — Oblique   lumbar   spine    position. 


62  ROENTGEN   TECHNIC 


Part. — Clavicle 

Size  of  Plate.     8x10,  if  one  is  to  be  taken;  11x14,  for  both. 

Diaphragm.     Large. 

Position.  Place  plate  under  clavicular  region,  having  placed  patient  on 
chest  (Fig.  32).  The  long  way  of  the  plate  should  run  from  side 
to  side  and  should  extend  well  out  to  the  shoulder  joint  and  high 
enough  up  so  that  the  upper  margin  extends  well  up  onto  the 
neck.  If  one  plate  of  both  are  to  be  taken,  an  11x14  should 
be  placed  crosswise  of  the  upper  chest,  the  upper  edge  extend- 
ing well  up  above  the  level  of  the  clavicles.  The  tube  should 
be  centered  over  the  spinous  process  of  the  second  or  third 
dorsal  vertebra.  The  same  instructions  regarding  the  holding 
of  the  breath  should  be  given  as  in  the  lumbar  spine,  for  if 
there  is  any  respiratory  movement  it  will  ruin  the  effect. 

Name  of  Plate.  Paragon   or   Seed's.  Cramer's. 

Number  of  Exposures.  One.  One. 

Spark  Gap.  5%  inches.  4^   inches. 

Milliamperage.  60  ma.  60  ma. 

Distance.  24  inches.  24  inches. 

Time.  1  second.  21/£  seconds. 


POSITIONS  AND   EXPOSURES 


63 


Fig.    32. — Clavicle   position. 


64  ROENTGEN   TECHXIC 


Part. — Scapula 

Size  of  Plate.     10x12. 
Diaphragm.     Large. 

Position.  Place  the  patient  the  same  as  for  taking  the  shoulder  except 
the  arm  on  -the  affected  side  should  be  raised  above  the  head 
(Fig.  33).  This  throws  the  scapula  toward  the  side  of  the  chest. 
The  plate  is  placed  under  the  scapular  region,  the  upper  edge 
extending  well  above  the  shoulder  lever,  the  inner  edge  extend- 
ing to  the  spine.  The  tube  is  centered  about  two  inches,  below 
the  clavicle  a  little  outside  the  mammillary  line. 

Name  of  Plate.  Paragon  or  Seed's.              Cramer's. 

Number  of  Exposures.  One.  One. 

Spark  Gap.  5%  inches.  4%  inches. 

Milliamperage.  80  ma.  60  ma. 

Distance.  18  inches.  22   inches. 

Time.  1   second.  2  seconds. 


POSITIONS   AND   EXPOSURES 


65 


Fig.    33. — Scapula  position. 


66  ROENTGEN   TECHNIC 


Part. — Sternum 

Size  of  Plate.     11x14. 

Diaphragm.     Lar*ge. 

Position.  This  is  the  most  difficult  bone  in  the  body  to  reproduce  success- 
fully. It  is  very  rarely  seen  well  done.  The  patient  must  be 
placed  in  the  oblique  position,  that  is,  being  laid  on  the  face  and 
then  turned  upward  one-quarter  turn.  A  deep  inspiration  must 
be  taken  and  held.  The  plate  is  placed  so  that  it  will  extend 
out  anteriorly  beyond  the  chest  wall  and  well  up  on  the  neck. 
The  tube  is  centered  over  its  center.  (Fig.  29.) 

Name  of  Plate.  Paragon  or  Seed's.  Cramer's. 

Number  of  Exposures.  One.  One. 

SparTc  Gap.  5%  inches.  6*4  inches. 

Milliamperage.  60  ma.  80  ma. 

Distance.  24  inches.  24  inches. 

Time.  l1^  seconds.  lJ/4  seconds. 


POSITIONS  AND   EXPOSURES  67 


Part. — Ribs 

Size  of  Plate.     11x14. 

Diaphragm.     Large. 

Position.  Place  the  patient  in  the  best  position  suited  to  bring  the  sup- 
posed fracture  nearest  the  plate.  This  is  usually  oblique, 
either  on  the  face  or  on  the  back  whichever  seems  best.  Center 
tube  so  principal  rays  will  fall  directly  over  painful  area.  In- 
struct patient  to  hold  breath  while  making  exposure.  It  is  al- 
ways advisable  to  place  a  lead  marker  over  the  suspected  lesion 
(a  lead  letter  stuck  to  the  center  of  a  piece  of  adhesive  plaster 
placed  over  the  area  is  good).  This  will  identify  the  exact  area 
on  the  finished  plate. 

Xame  of  Plate.  Paragon  or  Seed's.  Cramer's. 

X umber  of  Exposures.  One.  One. 

Spark  Gap.  6  inches.  4V6  inches. 

Milliamperagc.  60  ma.  60  ma. 

Distance.  24  inches.  22  inches. 

Time.  1  second.  2  seconds. 


68 


ROENTGEX   TECHNIC 


Part. — Urinary  Tract 

This  examination  is  not  complete  until  the  entire  tract  has 
been  taken,  that  is,  both  kidneys,  both  ureters,  and  the  bladder. 
It  has  been  demonstrated  many  times  that  a  stone  in  one 
kidney  may  give  pain  only  in  the  bladder,  and  vice  versa;  also 
a  stone  in  one  kidney  may  give  all  symptoms  seemingly  in  the 
opposite.  It  is  therefore  very  incomplete  to  examine  only  one 
part  with  the  possible  lesion  being  situated  in  another. 

Sise  of  Plate.     One,  11x14;  one,  8x10. 

Diaphragm.     Large  with  large  size  Hickey  cone. 

A  copious  water  enema  should  always  precede  this  examina- 
tion taken  in  the  recumbent  position ;  thus  clearing  the  colon  of 
all  feces  and  gas. 

Position.  The  11x14  plate  is  used  first,  taking  in  both  kidneys  and  both 
ureters  close  to  their  termination  in  the  bladder.  The  patient 
is  placed  on  the  back,  the  shoulders  and  knees  being  raised  and 
supported,  and  the  plate  being  placed  lengthwise,  running  from 
the  eighth  rib  behind  downward.  (See  Figs.  34  and  35.)  The 
tube  with  large  cone  attached  is  now  set  down  so  that  the  upper 
edge  of  the  cone  just  overlaps  the  costal  arch.  The  tube  is 
tilted  a  little  so  that  the  cone  will  conform  a  little  better  to  the 
slant  of  the  abdomen,  and  compression  is  made,  bringing  the 
spine  close  to  the  plate.  The  other  plate  takes  in  the  lower  ends 
of  both  ureters  and  the  bladder.  An  8x10  plate  is  used.  This 
is  so  placed  that  the  upper  edge  is  about  on  a  level  with  a  line 
dropped  from  the  navel.  The  lower  edge  of  the  large  Hickey 
cone  which  is  used  is  placed  so  that  it  just  overlaps  the  pubic 
arch  and  the  cone  tilted  slightly  so  that  the  rays  are  thrown 
slightly  into  the  pelvis,  that  is,  the  upper  edge  is  dropped  slightly 
in  the  abdomen.  (Fig.  35.)  Compression  is  made,  the  knees 
having  been  lowered  but  the  shoulders  still  being  raised  and 
supported.  At  the  time  of  both  these  exposures,  the  breath 
should  be  held. 


Name  of  Plate. 
Number  of  Exposures. 
Spark  Gap. 
Milliamperage. 
Distance. 

Time. 


Paragon  or  Seed's. 

Two. 

5%  inches. 

35  ma. 

Contact,  cone. 

About  22  inches. 

Kidney,  5  seconds 
(without  screen) . 
Bladder,  4  seconds 
( without  screen ;. 


Cramer 's. 

Two. 

4%   inches. 

60  ma. 

Contact,  cone. 

About  22  inches. 

Kidney,  3  seconds 
(with  screen).  Blad- 
der, 2%  seconds 
(with  screen). 


POSITIONS  AND  EXPOSURES 


69 


Fig.    34. — Kidney   position. 


Fig.    35. — Bladder   position    on    dorsum. 


70  ROENTGEN   TECHNIC 


This  is  a  branch  of  the  roentgenological  examination 
of  the  urinary  tract  that  is  used  by  some  workers,  very 
frequently.  It  consists  in  placing  in  the  kidneys  and 
ureters,  a  contrast  substance  so  that  they  may  be  shown 
the  same  as  the  stomach  is  when  filled  with  bismuth 
mixture.  There  are  several  methods  employed: 

1.  Metal  stylet  enclosed  in  ureteral  catheter. 

2.  Catheter  impregnated  with  bismuth. 

3.  Specially  prepared  ureteral  catheters,  known  as  x- 
ray  catheters. 

4.  Silver  solution  injection.     (Collargol  10  per  cent, 
Cargentos  20  per  cent.) 

5.  Thorium  solution  injection,  15  per  cent. 

The  patient  is  examined  cystoscopically,  using  an  in- 
strument rigged  for  double  catheterization.  After  both 
catheters  are  in  their  respective  ureters,  the  protruding 
ends  are  attached  to  a  graduated  glass  cylinder  holding 
150  c.c.,  and  the  solution  is  allowed  to  run  in  under  a 
very  low  pressure,  the  container  only  being  raised  a 
short  distance  above  the  patient.  Pressure  such  as  may 
be  applied  by  a  syringe  should  never  be  used  as  danger 
of  forcing  the  solution  out  into  the  kidney  substance  or 
even  of  rupturing  the  pelvis  becomes  very  possible.  Up- 
on the  first  sign  of  distress  being  evidenced  by  the  pa- 
tient, the  flow  is  immediately  shut  off  and  the  catheters 
removed.  The  amount  injected  for  both  kidneys  and 
ureters  should  never  exceed  15  c.c.  The  plate  having 
previously  been  placed  in  position,  the  tube  is  centered 
over  its  center  which  will  be  about  the  navel,  and  after 
instructing  the  patient  to  hold  an  inspiration,  the  ex- 
posure is  made.  This  wTill,  if  properly  performed,  show 
the  pelves  and  calices  filled,  as  well  as  both  ureters. 


POSITIONS  AND   EXPOSURES  71 

Tliis  reveals  a  very  good  idea  of  the  size  of  both  kidneys, 
their  position,  and  the  course  and  length  of  both  ureters. 
One  will  be  able  to  rule  out,  among  other  things,  ne- 
phroptosis  and  ureteral  kinks.  If  a  stone  is  in  the  ureter, 
the  solution  will  probably  not  pass  it,  but  stop  as  soon 
as  the  obstacle  is  met,  the  ureter  filling  from  there  down. 
An  opaque  injection  should  never  be  done  until  a  thor- 
ough examination  of  the  entire  tract  has  been  made, 
ruling  out  calculi,  which  of  course  would  be  obscured 
by  the  opaque  media  used.  If  nephroptosis  is  suspected, 
it  is  advisable  to  take  a  plate  not  only  in  the  prone  posi- 
tion but  also  standing  if  the  condition  of  the  patient 
warrants  it.  It  is  sometimes  desirable  to  demonstrate 
the  presence  or  absence  of  vesical  diverticula.  This  is 
best  accomplished  by  filling  the  bladder  by  means  of 
an  ordinary  rubber  catheter  attached  to  a  glass  cylinder 
containing  a  contrast  solution,  composed  of  either  of  the 
following  mixtures: 

Barium  sulphate  3  oz. 

Ol.  amydalse  dulcis  15  oz. 

Or 

Silver  iodide  2% 

Use  about  16  oz. 

All  or  as  much  as  can  be  comfortably  borne  is  injected, 
and  then  after  turning  the  patient  once  on  the  face  and 
back  again  to  distribute  the  solution,  the  exposure  is 
made. 


72 


ROENTGEN   TECHNIC 


Fig.    36. — Kidney   position. 

Part. — Kidneys,  Ureters,  and  Bladder.     (Injected.) 

Size  of  Plate.     14x17,  11x14,  and  8x10. 

Diaphragm.     Large,  with  large  Hickey  cone. 

Position.  One  plate  should  be  taken  with  the  patient  on  the  back,  the 
plate  being  placed  so  that  it  extends  well  under  the  ribs  poster- 
iorly. The  14x17  plate  should  be  used  without  diaphragm  or 
cone,  the  entire  tract  being  obtained.  Another  plate  (11x14) 
should  now  be  placed  so  that  its  upper  edge  extends  well  under 
the  posterior  ribs  and  using  the  large  size  cone  and  diaphragm, 
the  tube  is  tilted  so  that  it  fits  into  the  anterior  abdominal  wall 
under  the  costal  arch.  (See  urinary  tract  examination.)  Two 
8x10  plates  are  used  in  examining  the  injected  bladder.  With 
the  first,  the  patient  is  placed  on  the  back,  the  plate  and  tube 
being  located  the  same  as  for  the  bladder  examination.  With 
the  second,  it  is  well  to  place  the  patient  on  the  face,  putting 
the  plate  so  that  its  lower  edge  is  below  the  pubic  arch  about 
two  inches.  The  tube  with  large  cone  and  diaphragm  is  tilted  so 
that  the  principal  rays  strike  about  the  anal  opening.  (See 
Figs.  36,  37  and  38.) 


Name   of   Plate. 
Number  of  Exposures. 
SparTc  Gap. 
Milliamperage. 
Distance. 


Time. 


Paragon  or  Seed's. 

Three. 

5!/4  inches. 

35  ma. 

30  inches   (14x17). 

Contact  (11x14,  and  8x 
10). 

Kidney,  5  seconds 
(without  screen) . 
Bladder,  4  seconds 
(without  screen) . 
With  14x17  at  30 
inches,  9  seconds. 


Cramer 's. 
Three. 
414  inches. 
60  ma. 


Same. 

Kidney,  3  seconds  (with 
screen).  Bladder, 
2%  seconds  (with 
screen).  With  14x17 
at  30  inches,  5.8  sec- 
onds (with  screen). 


POSITIONS  AND   EXPOSURES 


73 


Fig.   37. — Bladder  position  on  dorsum. 


Fig.   38. — Prone  bladder  position. 


74  ROENTGEN   TECHNIC 

Chest  Examination 

The  clothing  having  been  removed,  the  patient  is  taken 
into  the  fluoroscopic  room  and  viewed  through  the  ver- 
tical instrument.  First,  the  two  apices  are  observed  by 
forming  the  diaphragm  aperture  into  a  horizontal  slit 
about  2l/2  by  8  inches.  The  patient  is  asked  to  take 
several  deep  inspirations  followed  by  a  cough.  By  this 
means  can  be  ascertained  whether  either  apex  fails  to 
fill  well  or  "light  up"  as  it  is  commonly  phrased.  Fol- 
lowing this  the  aperture  is  changed  to  a  vertical  slit 
somewhere  about  3  by  10  inches.  Both  hila  are  now  ex- 
amined to  note  any  thickening,  or  other  abnormality. 
At  this  time  the  heart  is  gone  over  hurriedly,  more  par- 
ticularly to  ascertain  the  presence  or  absence  of  aortic 
aneurysm.  The  shape  and  size  are  also  noted.  Follow- 
ing this,  both  complementary  spaces  (the  lung  tissue  ex- 
tending down  between  the  arch  of  the  diaphragm  and 
the  ribs)  are  observed  for  cloudiness,  the  patient  being 
instructed  to  breathe  deeply  several  times  so  that  the 
excursion  of  the  diaphragm  can  be  seen  on  both  sides. 
The  patient  is  now  turned  a  quarter  turn  to  the  left. 
The  heart  is  now  seen  at  the  operator's  right  and  the 
spine  to  the  left  with  the  clear  posterior  mediastinum 
between.  It  should  be  noted  whether  this  space  is  as 
clear  as  usual  or  whether  it  is  encroached  upon  by  glands 
or  enlarged  aorta.  After  this  the  diaphragm  is  opened 
to  its  fullest,  the  patient  is  brought  to  face  the  operator, 
and  the  chest  as  a  whole  is  viewed,  all  the  while  the  pa- 
tient breathing  deeply.  If  anything  of  interest  is  seen, 
such  as  areas  of  consolidation,  cavity  formation,  etc.,  it 
is  closed  down  upon  and  observed  more  in  detail.  This 
detail  is  at  its  best  only  partial,  for  plates  are  the  only 
satisfactory  method  of  registering  pulmonary  detail,  the 
fluoroscope  showing  practically  only  movement  and  cer- 
tain gross  pathology. 


POSITIONS  AND   EXPOSURES  75 

The  patient  is  now  reversed  with  back  to  screen  and 
practically  the  same  routine  is  gone  over  with.  The  case 
is  now  ready  for  the  roentgenogram. 

In  doing  chest  fluoroscopy  it  is  well  to  have  the  tube 
particularly  soft.  There  is  no  necessity  for  excessive 
penetration,  the  lung  being  of  such  a  spongy  character, 
and  the  wealth  of  detail  thereby  produced  is  an  exten- 
sive help  in  differentiating  the  various  types  of  pathol- 
ogy met  with. 


76 


ROENTGEN   TECHNIC 


Part. — Chest 

Size  of  Plate.     14x17. 

Diaphragm.     None. 

Position.  Patient  lies  on  chest,  face  straight  ahead,  with  forehead  rest- 
ing on  table.  The  upper  border  of  the  plate  should  be  well  up  un- 
der the  chin.  Hands  and  arms  at  side  with  palms  up.  A  deep 
inspiration  is  taken  and  the  exposure  made.  (Fig.  39.) 


Name  of  Plate. 
Number  of  Exposures. 


SparTc  Gap. 
Milliamperage. 
Distance. 
Time. 


Paragon  or  Seed's. 

One. 

Some  workers  prefer 
that  the  chest  always 
be  taken  stereoscopi- 
cally.  This  is  a  mat- 
ter of  preference. 

S1/^  inches. 

60  ma. 

30  inches. 

1%  seconds. 


Cramer 's. 
One. 


5\<2  inches. 
60  ma. 
24  inches. 
1%  seconds. 


POSITIONS  AND   EXPOSURES 


t  I 


78  KOENTGEN   TECHNIC 

Part. — Head 

Size  of  Plate.     8x10,  or  10x12. 

Diaphragm.     Large. 

Position.  In  looking  for  fractures  of  the  base  or  vault,  it  will  only  be 
necessary  to  take  stereoscopic  plates  with  the  head  first  on  one 
side  and  then  on  the  other,  but  if  the  sinuses  are  in  question,  to 
this  must  be  added  an  anteroposterior  and  an  inferoposterior. 
All  hairpins  and  ornaments  should  be  removed,  allowing  the  hair 
to  fall  loosely.  If  looking  for  a  suspected  fracture,  lay  the  head 
with  the  injured  side  down  next  the  plate,  resting  it  upon  the 
stereoscopic  box.  The  patient  lies  on  the  side  with  the  arm 
next  the  table  placed  behind  him.  This  brings  the  chest  against 
the  table  and  not  only  allows  the  head  to  remain  nearer  the 
table  but  insures  a  more  steady  position.  (See  Fig.  40.)  A 
stereoscopic  set  is  now  taken  as  heretofore  described,  the  long 
way  of  the  plate  being  placed  from  before  backward.  When 
the  accessory  sinuses  are  desired,  two  plates  are  required.  With 
the  first  the  patient  is  placed  face  downward  with  the  chin  rest- 
ing on  an  8x10  running  from  above  downward.  The  head  is 
so  placed  that  while  the  chin  rests  on  the  plate,  the  tip  of  the 
nose  is  about  one-half  inch  distant  from  it.  A  large  Hickey 
cone  is  used  and  is  brought  down  so  that  it  envelops  the  head, 
the  principal  rays  being  directed  through  the  malar  promi- 
nences. By  assuming  this  position,  the  petrous  portions  of  the 
temporals  are  thrown  downward  so  that  they  do  not  obstruct 
the  antra  of  Highmore.  By  using  this  position,  one  is  enabled 
to  compare  as  to  density,  both  frontals,  both  antra,  anterior  and 
posterior  ethmoids  on  both  sides,  and  both  mastoids  to  a  lim- 
ited degree;  this,  however,  not  being  the  best  position  for  mas- 
toids. Besides  the  sinuses  this  position  shows  not  only  the 
general  conformation  of  the  face  but  certain  minor  things  like 
the  nasal  septum,  and  parts  of  the  turbinates.  The  lower  jaw, 
especially  the  anterior  portion  containing  the  central  and  lateral 
incisor  teeth,  comes  out  quite  clearly.  If  now  with  one  lateral 
view  the  sphenoid  cells  are  seen  to  be  clear,  all  has  been  done 
that  is  necessary;  but  if  this  area  looks  cloudy,  an  infero- 
superior  view  should  be  obtained. 

For  this  the  patient  is  placed  on  the  back  with  the  head  hang- 
ing over  the  end  of  the  table  as  far  as  possible  (Fig.  41).  A 
stool  is  now  placed  under  the  crown  of  the  head  with  an  8x10 
plate  interposed.  This  plate  should  be  parallel  to  a  plane 
drawn  through  the  external  auditory  meatus  and  the  superciliary 
ridge.  The  tube  with  the  small  Hickey  cone  is  placed  so  that 
the  end  of  the  cone  comes  under  the  chin,  the  principal  rays 
striking  the  plate  at  right  angles.  This  will  show  the  butterfly- 
shaped  sphenoid  bone  with  the  sphenoid  cells  in  the  center. 
Both  sides  can  now  be  compared  for  any  difference  in  their 
density.  The  anteroposterior  head  position  is  shown  in  Fig.  42. 
If  the  case  is  one  for  general  diagnosis  of  some  indefinite 
head  lesion,  stereoscopic  plates  should  be  taken  from  both  sides. 


POSITIONS  AND   EXPOSURES 


Fig.  40. — Lateral  head  position. 


Fig.   41. — Inferosuperior  head  position. 


80 


ROENTGEN   TECHNIC 


Fig.   42. — Anteroposterior  head  position. 


In  case  the  frontal  bone  itself  is  in  question,  it  should  be 
placed  directly  in  contact  with  the  envelope  so  as  to  bring  out 
as  much  detail  as  possible. 

The  head  is  the  only  part  of  the  body  where  a  stereoscopic 
view  must  be  taken  from  both  sides,  and  it  is  only  from  the 
fact  that  the  head  is  so  thick  that  the  side  away  from  the 
plate  is  not  distinct  enough  .to  make  out  the  detail  necessary. 
In  a  lateral  stereoscopic  view  of  the  head,  the  half  of  the  head 
nearest  the  plate  shows  up  with  great  distinctness  while  the 
far  side  is  very  hazy.  By  reversing  the  process,  both  sides  are 
brought  out  with  the  maximum  of  detail. 


Name  of  Plate. 
Number  of  Exposures. 


Sparlc  Gap. 
Milliamperage. 
Distance. 
Time. 


Paragon  or  Seed's  only. 

Fracture  of  vault:      Two,  stereoscopical. 

Sinuses:  Two,  one  lateral,  one  anteroposterior. 
(One,  below  upward,  if  necessary.) 

Indefinite  pathology:  Four,  double  stereoscopi- 
cal. 

GI/J  inches. 

40  ma. 

Anteroposterior,  20  inches;   lateral,  18  inches. 

Anteroposterior,  5  seconds,  lateral,  2  seconds. 


POSITIONS  AND   EXPOSURES 


81 


Fig.  43. — Mastoid  position. 

Part. — Mastoids 

Size  of  Plate.     5x7. 

Diaphragm.     Small.     Small  Hickey  cone. 

Position.  In  mastoid  work  a  plate  should  always  be  taken  of  both  sides, 
so  that  they  can  be  compared  when  finished.  The  patient  is  laid 
on  one  side  with  the  arm  next  the  table  placed  behind  the  body, 
the  same  as  was  suggested  in  the  lateral  head  position.  The 
head  rests  on  a  wedge,  the  base  of  which  is  raised  from  the  table 
about  4  inches,  the  thin  edge  being  placed  under  the  neck  and 
the  thick  side  under  the  side  of  the  head.  This  throws  the 
head  at  an  angle  of  about  30  degrees  from  the  horizontal  (Fig. 
43).  The  plate  is  now  placed  with  the  mastoid  in  the  center, 
the  ear  being  turned  forward  so  as  not  to  overlap  the  cells. 
The  tube  is  centered  a  little  below  and  posterior  to  the  parietal 
eminence  so  that  the  central  rays  will  strike  the  process  as  it 
layte  on  the  plate.  This,  of  course,  will  cause  the  rays  to  strike 
the  plate  at  an  angle  of  about  60  degrees,  but  what  distortion 
there  is  makes  no  difference  as  both  sides  are  taken  the  same 
way  and  are  thus  in  proportion. 


Name  of  Plate. 

Number  of  Exposures. 

SparTc  Gap. 

Milliamperage. 

Distance. 

Time. 


Paragon  or  Seed's  only. 

Two. 

6%  inches. 

40  ma. 

Cone  almost  in  contact. 

2%  seconds. 


82  ROENTGEN   TECHNIC 


Part. — Lower  Jaw 

Size  of  Plate.     5x7. 

Diaphragm.     Medium  with  a  medium  Hickey  cone. 

Position.  The  patient  is  placed  in  the  same  position  as  for  a  mastoid 
plate  except  the  wedge  is  reversed,  that  is,  the  thick  edge  is 
placed  under  the  neck,  letting  the  head  fall  over  it  (Fig.  44). 
It  is  necessary  that  the  neck  be  stretched  to  its  fullest  extent. 
This  is  imperative  for  by  so  doing  the  side  of  the  jaw  not 
wanted  and  farthest  from  the  plate  will  be  thrown  out  of  range 
of  the  rays.  The  tube  and  cone  are  tilted  so  that  the  principal 
rays  will  strike  directly  on  the  jaw  against  the  plate,  being  cen- 
tered just  in  front  of  the  larynx.  This,  of  course,  throws  the 
rays  at  an  angle  to  the  plate  of  about  60  degrees  which  causes 
some  distortion,  but  a  satisfactory  plate  results. 

Name  of  Plate.  Paragon  or  Seed's  only. 

Number  of  Exposures.  One. 

Spark  Gap.  4^  inches. 

Milliamperage.  60  ma. 

Distance.  About  22  inches. 

Time.  3  to  4  seconds. 


POSITIONS  AND   EXPOSURES 


83 


Fig.  44. — Mandible  position. 


84  ROENTGEN   TECHNIC 


Part. — Teeth 

Size  of  Plate.     Dental  film  iy4xl%    (negative). 

Diaphragm.     Small  with  small  Hickey  cone. 

Position.  The  film  is  placed  inside  the  jaw  opposite  the  tooth  to  be  taken 
so  that  the  tooth  and  alveolar  process  are  interposed  between 
it  and  the  rays.  The  tube  is  now  tilted  so  that  the  principal 
rays  will  strike  the  film  at  right  angles.  This  is  very  im- 
portant, for,  if  not  done,  the  apices  of  the  roots,  the  most  im- 
portant part,  will  not  get  on  the  film,  the  teeth  appearing  very 
long,  extending  all  the  way  across  the  film.  If  the  rays  strike 
the  film  properly,  the  tooth  will  be  seen  normal  in  size.  Always 
be  sure  that  the  film  edge  is  about  on  a  level  with  the  chew- 
ing edge  of  the  tooth,  this  will  insure  the  apex  on  the  film 
with  sufficient  bone  tissue  surrounding  it  to  be  satisfactory. 
The  patient  should  be  made  to  hold  the  films  with  the  finger 
or  thumb  if  possible.  (See  Figs.  45  and  46.) 

Number  of  Exposures.  Usually  three  teeth  side  by  side  can  be  taken  on 
one  film.  It  requires  ten  films  to  include  all  of  the  teeth. 

Spark  Gap.     4%  inches. 

Milliamperage.     60  ma. 

Distance.     Almost  cone  contact. 

Time.  %  second  for  uppers ;  trifle  less  for  lowers  as  the  cone  can  be  placed 
closer,  usually  about  ^  second. 


POSITIONS  AND   EXPOSURES 


85 


Fig.   45. — Position   in    taking   upper   teeth. 


Fig.  46. — Position  in  taking  lower  teeth. 


86  ROENTGEN   TECHNIC 


Part. — Gall  Bladder 

Size  of  Plate.     8x10. 

Diaphragm.     Medium  with  medium  Hickey  cone. 

Position.  The  plate  is  so  placed  that  its  center  is  directly  under  a  point 
on  the  right  costal  arch  at  the  junction  of  the  middle  with  the 
inner  third.  The  patient  is  rotated  a  little  to  the  right,  bring- 
ing the  right  side  close  to  the  plate  (Fig.  47).  The  cone  is 
brought  down  so  that  its  upper  edge  lies  below  the  last  rib  at 
a  point  about  equal  distance  from  the  spinous  processes  and  the 
axillary  line.  The  tube  is  tilted  slightly  upward  and  imvanl. 
The  patient  is  instructed  to  take  a  deep  inspiration  and  hold  it 
during  the  exposure. 

Name  of  Plate.  Paragon  or  Seed's.  Cramer's. 

Number  of  Exposures.      4  to  6.  4  to  6. 

Spark  Gap.  5%   inches.  4^  inches. 

MUlia-mpcra(jc.  35  ma.  60  ma. 

Distance.  Almost   cone   contact.  Almost  cone  contact. 

Time.  1%   to  3  seconds   (with  2  seconds  (with  screen). 

screen ) .      Average,    2 

seconds. 


POSITIONS  AND   EXPOSURES 


Fig.  47. — Gall  bladder  position. 


88  ROENTGEN  TECHNIC 

Examination  of  the  Esophagus 

This  examination  is  made  to  determine  stenosis  re- 
sulting from  malignancy,  chemical  action  (lye,  phenol, 
etc.),  spasm,  pressure  from  the  outside,  possibly  from 
enlarged  or  malignant  mediastinal  glands,  aneurysm  of 
aorta,  and  spinal  disease. 

Fluoroscope. — The  patient  is  placed  in  the  oblique  posi- 
tion ;  viz.,  turned  a  quarter  turn  to  the  right,  just  enough 
to  allow  the  posterior  mediastinum  to  show  clearly.  In 
order  to  view  the  wall  of  the  esophagus  properly,  it 
should  be  coated  with  a  mixture  somewhat  more  ad- 
hesive than  the  ordinary  buttermilk  mixture.  Hirsch, 
of  New  York,  in  a  recent  communication  recommended 
the  following: 

A  teaspoonful  of  mucilage  of  acacia  is 
stirred  up  with  a  heaping  tablespoonful  of 
bismuth  subcarbonate.  Stirring  should  con- 
tinue for  ten  minutes  or  until  the  mixture 
assumes  a  syrupy  consistency. 

A  teaspoonful  of  this  is  sufficient  to  cover  the  entire 
tract  and  it  remains  long  enough  to  view  the  tube  with 
some  deliberation.  Peristaltic  waves  can  be  seen,  ex- 
ternal points  of  pressure  can  be  noted  and  irregularities 
in  the  contour  can  be  shown.  Normally,  the  tract  is  clear 
in  a  few  minutes,  if,  however,  any  lesion  exists,  the  coat- 
ing will  remain  considerably  longer.  After  taking  plenty 
of  time  to  view  the  coated  tract  (giving  more  mixture 
if  necessary),  turning  the  patient  a  quarter  turn  not  only 
to  the  right  but  also  to  the  left  and  straight  forward, 
one  plate  or  a  stereoscopic  set  is  taken  preferably  with 
the  patient  standing  in  the  right  oblique  position,  al- 
though if  necessary  it  can  be  done  lying  in  the  same 
position  as  for  an  oblique  view  of  the  stomach.  (See  gas- 
trointestinal technic.) 


POSITIONS  AND   EXPOSURES 


89 


Fig.   48. — Position  for  esophagus. 


Part. — Esophagus 

Size  of  Plate.     11x14. 

Diaphragm.     Large  with  large  Hickey  cone. 

Position.  Oblique  (quarter  turn).  Right  breast  to  plate.  Preferably 
standing,  but  not  necessarily  so.  The  patient  is  placed  in  the 
position  to  be  assumed,  and  is  directed  to  take  a  fresh  swallow 
of  the  contrast  mixture  so  as  to  be  sure  to  have  some  in  the 
tube  at  the  time  of  exposure.  The  patient  is  told  to  hold  the 
breath,  and  the  exposure  is  made.  (See  Fig.  48.) 


Name  of  Plate. 
Milliamperage. 
Spark  Gap. 
Distance. 
Time. 


Paragon  or  Seed's. 
60  ma. 
5lfa  inches. 
24  inches. 
1   second. 


Cramer 's. 
80  ma. 
5%  inches. 
30  inches. 
1*4  seconds. 


90  ROENTGEN   TECHNIC 

Gastrointestinal  Examination 

The  patient,  having  fasted  for  at  least  eight  hours, 
presents  himself  and  is  prepared  the  same  as  for  a  chest 
examination,  that  is,  all  the  clothing  is  removed,  and  a 
kimono  slipped  on.  (If  a  male,  only  the  clothing  to  the 
waist  line  need  be  taken  off,  the  pants  being  slipped  down 
when  the  exposures  are  made.)  He  is  now  taken  into 
the  roentgenographic  room  where  plates  are  made  of 
the  gall  bladder.  This  is  very  essential  as  a  routine  in 
all  gastrointestinal  examinations  trying  to  show  gall 
stones,  for  it  can  not  be  done  after  the  contrast  meal  has 
been  given  for  fear  of  any  stones  that  might  be  present 
being  covered  by  the  opaque  media.  (See  gall  bladder 
examination.)  The  opaque  or  contrast  meal  is  now  pre- 
pared. There  are  various  mixtures  used.  Of  the  opaque 
ingredients  bismuth  subnitrate,  bismuth  subcarbonate,  or 
bismuth  oxychloride  in  2  ounce  doses,  or  barium  sul- 
phate 5  ounces  are  the  most  common.  On  account  of 
the  difficulty  in  obtaining  chemically  pure  bismuth  salts, 
barium  sulphate  is  the  safest  preparation  besides  being 
considerably  less  expensive.  It  does  not  obstruct  the 
rays  quite  as  well  as  bismuth,  but  if  given  in  large  enough 
doses,  is  very  satisfactory.  Various  vehicles  in  which 
to  suspend  the  contrast  substance  have  been  used ;  name- 
ly, cream  of  wheat,  farina,  potato  pap,  mucilage  of  acacia, 
malted  milk,  gruel,  corn  meal  mush,  buttermilk,  and  va- 
rious other  things.  Any  one  of  them  is  satisfactory ;  but 
for  routine  office  work,  the  buttermilk,  either  as  obtained 
from  the  drug  store  soda  fountain  or  prepared  by  one 
of  the  various  buttermilk  tablets  on  the  market,  is  ac- 
ceptable. Sixteen  ounces  are  required.  One  meal  should 
be  adopted  and  maintained  as  a  standard,  for  switching 
from  one  to  another  will  lead  to  trouble,  all  of  them  giv- 
ing varying  results,  such  as  filling  of  the  stomach  and 
duodenum,  emptying  time,  etc. 


POSITIONS  AND   EXPOSURES  91 

Having  prepared  the  meal,  it  is  placed  within  easy 
reach,  and  a  hurried  examination  is  made  of  the  chest, 
just  to  rule  out  any  gross  pathology  that  may  have  gone 
unnoticed.  The  patient  is  now  placed  in  the  oblique 
position  the  same  as  for  viewing  the  posterior  medias- 
tinum, the  container  holding  the  contrast  mixture  is  held 
in  the  patient's  left  hand  and  he  is  directed  to  take  a 
few  swallows.  The  meal  is  now  viewed  by  the  aid  of 
the  vertical  aperture  as  it  passes  from  the  mouth  to  the 
cardia.  This,  in  a  rough  way,  determines  whether  there 
is  any  marked  stenosis  or  spasm  of  the  esophagus.  After 
this  has  been  determined,  the  stomach  is  viewed,  notic- 
ing any  irregularities  such  as  notches,  hourglass  contrac- 
tions or  marked  filling  defects.  The  patient  is  now 
turned  forward  and  the  rest  of  the  meal  is  directed  to 
be  taken.  When  the  full  amount  has  been  ingested,  the 
stomach  is  viewred  as  a  whole,  noting  its  shape,  size  and 
position.  If  peristalsis  does  not  take  place  after  a  few 
moments,  the  patient  is  allowed  to  sit  down  for  ten  or 
fifteen  minutes,  after  which  waves  will  probably  be  no- 
ticed traveling  from  the  cardia  downward,  especially  on 
the  greater  curvature.  The  number,  depth,  and  rapidity 
of  these  will  be  noted,  as  well  as  the  pylorus  and  first 
part  of  the  duodenum.  A  normal  duodenum  in  its  first 
part  (cap)  will  be  plainly  visible  as  a  sort  of  a  triangular 
body  with  its  base  joining  the  pyloric  sphincter  which 
will  be  noticed  as  a  narrowing.  If  there  seems  to  be  a 
sluggishness  in  the  filling  of  the  duodenal  cap,  a  little 
pressure  in  the  prepyloric  region  will,  if  normal,  fill  it 
out  and  will  probably  reveal  the  descending  (second) 
portion,  which  is  finally  lost  behind  the  antrum  of  the 
stomach  as  it  approaches  the  ligament  of  Treit.  The  en- 
tire organ  should  be  palpated  to  ascertain  freedom  of 
movement,  filling  defects  or  notches.  When  all  data  ob- 
tainable have  been  elicited,  the  patient  is  taken  into  the 
roentgenographic  room  and  plates  of  the  stomach  made. 


92 


KOKNTCKN    TKCIIXIC 


Part. — Stomach  and  Duodenal  Cap 

Size  of  Plate.     11x14. 

Diaphragm.     Large. 

Position.  From  the  fact  that  the  cap,  first  portion  of  the  duodenum,  fills 
best  in  the  prone  position,  from  one  to  three  plates  :ire  made 
with  the  patient  lying  on  the  face  (Fig.  49).  The  plate  (11x14) 
is  placed  under  the  belly  lengthwise,  estimating  the  position  of 
the  stomach  from  what  has  been  seen  with  the  fluorosrope. 
(It  usually  is  from  four  to  five  inches  higher  when  lying  than 
when  standing).  After  these  have  been  taken,  the  patient  is 
turned  a  quarter  turn  so  that  he  is  lying  slightly  on  the  right 
side,  the  plate  having  been  slipped  under  previously.  This  not 
only  brings  the  very  important  pylorus  and  cap  near  the  plate  but 
it  shows  the  stomach  in  a  different  position.  This  is  called  the 
oblique  position  (Fig.  50)  and  by  some  is  thought  very  impor- 
tant. The  standing  posture  is  now  assumed  (Fig.  51).  The 
tube  is  tilted  so  that  the  rays  pass  parallel  to  the  floor.  The 
table  is  tilted  to  the  vertical  position  supporting  the  plate,  and 
the  patient  interposed.  The  stomach  now,  of  course,  will  be 
in  the  same  position  as  when  viewed  with  the  vertical  fluoro- 
scope,  and  the  height  of  the  plate  will  be  determined  accord- 
ingly. The  patient  must  be  instructed  to  stand  very  close  to 
the  table  with  the  hands  resting  on  the  edge,  else  due  to  un- 
steadiness on  the  feet,  movement  will  take  place.  Before  each 
gastrointestinal  exposure  is  made,  the  breath  must  be  held. 


Fig.   49. — Prone  stomach  position. 


POSITIONS  AND   EXPOSURES 


93 


Fig.   SO. — Oblique  stomach   position. 


Fig.    51. — Standing  stomach   position. 


94  ROENTGEN   TECHNIC 

\arnc  of  Plate.                    Paragon   or    Seed's.  Cramer's. 

Number  of  Exposures.      3   to   6.  3   to  6. 
Spark   Gap. — 

Size  of  Patient. — 

f  Prone,  6l/2  in.  (without  screen)  [Prone,  6%  in.   (with  screen) 

Small          •<  Oblique,  t>l/2  in.   (without  screen)  •<  Oblique,  6}/2  in.   (with  screen) 

I  Standing,  6l/2  in.   (without  screen)  [Standing,    6l/2    in.    (with   screen) 

f  Prone,  t>l/2  in.  (without  screen)  f  Prone,  6l/2  in.   (with  screen) 

Medium     -j  Oblique,  f>]/2  in.  (without  screen)  -I  Oblique,  6l/2  in.   (with  screen) 

[Standing,  6l/2  in.   (without  screen)  [Standing,    6%    in.    (with   screen) 

[Prone,  7  in.    (without  screen)  f  Prone,   7  in.    (with  screen) 

Large          •<  Oblique,   7   in.    (without  screen)  -I  Oblique,   7  in.    (with  screen) 

I  Standing,   7   in.    (without  screen)  I  Standing,   7   in.    (with   screen) 

Milliasnperage, — 

{Prone,  90  ma.  (without  screen)  f  Prone,    90   ma.    (with    screen) 

Oblique,  90  ma.  (without  screen)  -<  Oblique,  90  ma.    (with  screen) 

Standing,  90  ma.  (without  screen)  [Standing,    90   ma.    (with   screen) 

I  Prone,  100  ma.  (without  screen)  [Prone,   100  ma.    (with  screen) 

Medium      •<  Oblique,  100  ma.   (without  screen)  <  Oblique,   100  ma.   (with  screen) 

I  Standing,   100  ma.  (without  screen)  I  Standing,   100  ma.    (with  screen) 

f  Prone,  120  ma.   (without  screen)  f  Prone,   120  ma.   (with  screen) 

Large          \  Oblique,  120  ma.   (without  screen)  J.  Oblique,  120  ma.  (with  screen) 

I  Standing,  120  ma.  (without  screen)  I  Standing,   120  ma.    (with  screen) 

Distance. — •        I  Lying    and    standing,    22    in.  Same 
|  Oblique,     24    in. 

Time. — 

f  Prone,  V3  sec.   (without  screen)  f  Prone,  Vs  sec.    (with  screen) 

Small          •<  Oblique,  ^  sec.   (without  screen)  -<  Oblique,   J4  sec.   (with  screen) 

I  Standing,   l/i  sec.   (without  screen)  I  Standing,    Y?    sec.    (with   screen) 

f  Prone,   l/i   sec.    (without  screen)  f  Prone,   Yi  sec.    (with  screen) 

Medium      -|  Oblique,  1  sec.   (without  screen)  <  Oblique,    1    sec.    (with   screen) 

[Standing,  ^  sec.  (without  screen)  [Standing,    ^    sec.    (with   screen) 

f  Prone,   Ya,  sec.    (without  screen)  f  Prone,   34   sec.    (with  screen) 

Large          -I  Oblique,  \l/2  sec.  (without  screen)  •<  Oblique,    \l/2    sec.    (with   screen) 

[  Standing,  1  sec.   (without  screen)  [_  Standing,    1    sec.    (with    screen) 


Serial  Roentgenography 

Very  frequently  it  is  advisable  to  have  several  views 
of  the  antrum  of  the  stomach,  the  pyloric  sphincter,  and 
the  duodenal  cap,  so  that  a  complete  cycle  may  be  viewed. 
With  this  in  mind,  the  author's  colleague,  Doctor  A.  F. 
Tyler,  and  the  author  designed  and  put  in  operation 
a  table  which  accomplishes  this  in  a  very  satisfactory 


POSITIONS  AND    EXPOSURES 


95 


manner.  (See  Figs.  52  and  53.)  It  is  made  to  hold  a 
14x17  plate,  obtaining  sixteen  views  on  same,  which  meas- 
ure 31/2  by  414  inches  each.  After  the  usual  plates  are 
taken,  this  apparatus  is  laid  upon  the  roentgenographic 
table,  the  patient  being  placed  on  it  face  downward  and 


96 


ROENTGEN  TECHNIC 


the  exposures  made  in  rapid  succession ;  the  whole  opera- 
tion consuming  about  one  minute  or  less.  At  times,  this 
is  a  great  help  in  clearing  up  some  obscure  point.  The 
box  in  which  the  plate  holder  plays,  measures  29  by  35  by 
2iy2  inches,  inside  measurements.  The  holder  is  one 
taken  from  a  Kelley-Koett  table  with  two  handles  at- 
tached to  one  side.  This  runs  forward  and  backward,  as 


Fig.   53. — Showing  serial   plate  apparatus  tilted   upward   when  not  in   use. 


POSITIONS  AXD   EXPOSURES  97 

well  as  from  side  to  side,  somewhat  the  same  as  a  tube 
in  a  horizontal  fluoroscope,  there  being  a  track  running 
in  both  directions.  The  back  and  both  ends  are  enclosed, 
leaving  the  front  open.  The  top  is  lined  with  one-eighth 
inch  lead  having  a  square  opening  in  the  center  S1/^  by 
41/4  inches.  On  the  front  edge  of  the  top,  there  are  two 
spring  snaps  opposite  the  two  handles.  When  the  plate 
holder  is  in  position,  it  can  be  moved  the  required  dis- 
tance, 41/4  inches,  and  stopped.  On  the  handles,  which 
are  circular  steel  rods,  there  are  lugs  every  8^2  inches. 
The  holder  is  started  from  one  end,  after  having  been 
pushed  into  the  back  of  the  box  and  moved  four  spaces, 
each  4l/4  inches,  it  is  then  pulled  out  to  the  first  lug, 
31/2  inches  and  returned  in  another  four  spaces  or  inter- 
vals. This  is  repeated  until  all  sixteen  spaces  are  cov- 
ered. 

In  order  to  locate  the  sphincter  over  the  center  of  the 
given  space,  the  patient  is  first  placed  face  downward 
on  the  horizontal  fluoroscope,  the  duodenum  and  pylorus 
located,  and  a  small  cross  with  a  skin  pencil  made,  the 
intersection  being  over  the  sphincter.  After  this,  the 
patient  is  laid  face  downward  on  the  table;  a  steel  rod 
bent  to  a  right  angle  is  set  into  a  socket  placed  on  the 
back  side  of  the  table  which  has  an  adjustable  line  hang- 
ing from  its  tip  with  a  plumb  bob  on  the  end.  It  was 
determined  in  the  placing  of  this  socket  and  in  figuring 
the  length  of  the  horizontal  arm,  that  the  plumb  bob 
would  fall  squarely  over  the  center  of  the  opening  so 
when  the  patient  is  in  position  and  his  body  adjusted 
so  that  the  plumb  points  squarely  over  the  intersection 
of  the  cross,  it  is  known  that  the  pylorus  too  is  squarely 
over  the  opening.  The  rod  is  now  removed  and  the  tube 
with  the  small  diaphragm  and  cone  are  centered  over  the 
cross. 

Following  this  the  patient  is  directed  to  return  at  the 
end  of  six  hours  (fasting)  so  that  the  emptying  time 


98  ROENTGEN  TECHNIC 

may  be  ascertained  fluoroscopically.  (Repeated  exam- 
inations have  shown  that  a  normal  stomach  should  be 
entirely  empty  at  this  time  if  given  buttermilk  mixture.) 
If  the  stomach  is  not  empty  at  this  time,  the  cause,  if 
possible,  should  be  learned,  a  plate  being  taken  not  only 
to  record  it,  but  to  lend  any  possible  aid  in  ascertaining 
the  delay.  The  plate  will  also  show  how  far  the  head 
of  the  meal  has  advanced,  how  much  still  remains  in  the 
ileum,  etc.  Twenty-four  hours  following  the  ingestion 
of  the  meal  (18  hours  following  last  observation)  the  pa- 
tient presents  himself  again,  having  been  given  permis- 
sion to  take  food,  if  desired,  but  no  enema  or  laxative 
having  been  allowed.  (If  the  stomach  is  not  empty  at 
six  hours,  it  is  desirable  to  observe  the  case  every  few 
hours  if  convenient  until  emptying  has  taken  place  and 
a  note  made  of  it.)  At  this  time,  the  colon  should  nor- 
mally be  filled  as  viewed  by  the  fluoroscope.  It  should 
be  determined  by  palpation  whether  the  colon  is  freely 
movable;  whether  any  adhesions  are  present,  either  to 
surrounding  parts  or  from  one  part  of  the  gut  to  an- 
other; whether  the  appendix  shows  (it  does  at  this  time 
in  about  75  per  cent  of  cases)  and  if  so,  whether  it  is 
freely  movable,  bound  down  in  the  pelvis  or,  possibly  up 
behind  the  cecum  (retrbcecal),  whether  it  is  tender  to 
pressure;  whether  there  is  an  elongated  sigmoid  loop, 
how  much  ptosis  is  present,  if  any,  and  whether  the 
cecum  or  ascending  colon  are  beginning  to  empty  or  not 
and  anything  further  that  may  help  in  reaching  a  cor- 
rect diagnosis.  A  plate  is  taken  at  this  time,  especially 
so  if  the  appendix  is  visible.  The  case  may  from  now 
on  be  followed  by  means  of  the  fluoroscope  only  (unless 
something  of  interest  presents  itself  which  should  be 
permanently  recorded  on  a  plate).  The  horizontal  ap- 
paratus is  used  at  any  one  of  these  observations  if  any 
further  information  can  be  obtained,  as  for  instance,  a 
transverse  colon  that  sags  down  into  the  pelvis  and  can 


POSITIONS  AND   EXPOSURES  99 

not  be  raised  in  the  standing  position,  may  come  up 
readily  if  the  patient  is  placed  on  the  back.  Adhesions 
at  this  point  can  sometimes  only  be  demonstrated  in  this 
manner. 

From  now  on  the  case  is  usually  nothing  more  than 
determining  whether  a  colon  stasis  exists,  and  if  so,  of 
how  many  hours.  Most  authorities  give  from  36  to  48 
hours  as  the  time  the  patient  should  be  entirely  free 
from  the  whole  meal. 

If  the  pathology  is  thought  from  the  first  to  be  located 
wholly  in  the  intestines  with  the  possible  exception  of  an 
involved  appendix,  an  opaque  enema  should  be  adminis- 
tered (the  bowel  having  been  previously  emptied  by  a 
two  quart  water  enema).  Here  it  may  be  stated  that  in 
the  author's  opinion  there  is  only  one  proper  position 
to  have  a  patient  assume  in  taking  an  enema  to  fill  the 
colon;  that  is,  first,  place  him  on  the  left  side  and  insert 
the  tube,  having  the  container  raised  about  three  feet. 
The  liquid  is  now  allowed  to  flow  into  the  bowel  until 
about  half  of  it  is  taken;  he  is  now  turned  over  so  that 
he  is  lying  flat  on  the  face,  and  the  remainder  is  given. 
If  this  method  is  carried  out,  there  will  usually  be  no 
griping  and  little  desire  to  expel  the  fluid.  He  is  now 
turned  onto  the  back,  the  tube  having  been  removed; 
and  after  the  knees  have  been  drawn  up,  the  abdomen  is 
lightly  kneaded  so  as  to  insure  a  thorough  distribution 
of  the  liquid. 

The  enema  is  prepared  in  various  ways,  two  common 
and  satisfactory  methods  being  as  follows :  To  one  quart 
of  heavy  buttermilk  add  5  ounces  of  one  of  the  bismuth 
salts  or  8  ounces  of  barium  sulphate.  This  is  placed  in 
an  ordinary  irrigating  can  and  warmed  by  placing  the 
can  in  a  sink  or  pail  of  hot  water  and  agitating  the  con- 
tents, either  with  the  hand  or  with  a  long-handled  spoon. 
This  also  keeps  the  heavy  powder  from  settling  to  the 
bottom  and  thereby  clogging  the  outlet  tube.  The  sec- 
ond and  probably  the  better  way  is  as  follows:  To  32 


100  ROEXTGEX   TECHNIC 

ounces  of  warm  water  add  7l/o  ounces  of  barium  sul- 
phate, and  1.5  ounces  of  kaolin.  This  after  being  well 
stirred  is  injected.  Following  the  injection,  the  patient 
is  viewed  fluoroscopically.  The  same  things  are  noted 
as  seen  subsequent  to  a  meal  from  above  with  the  excep- 
tion that  the  appendix  rarely  shows  when  the  contrast 
mixture  is  given  from  below.  Ileocecal  incontinence 
should  also  be  looked  for  as  this  is  the  only  method  by 
which  it  may  be  demonstrated.  It  is  sometimes  advis- 
able, especially  if  malignancy  is  suspected,  to  watch  the 
enema  injected  by  means  of  the  horizontal  instrument. 
This  will  reveal  any  point  or  points  of  hesitation,  etc., 
which  may  be  exceedingly  helpful.  The  different  parts 
of  the  gastrointestinal  tract  should  never  be  examine;! 
separately,  a  meal  should  always  accompany,  and  care- 
ful observations  be  made  of  it  until  it  is  wholly  expelled. 

Kuegle  Technic 

There  has  been  an  exposure  table  worked  out  by  an- 
other of  the  author's  colleagues,  Doctor  F.  H.  Kuegle, 
which  probably  puts  exposures  on  a  more  exact  basis 
than  any  other  that  has  been  observed  by  the  author. 
With  it,  especially  in  bone  work,  a  medium  spark  gap 
is  used  together  with  a  small  number  of  milliamperes 
and  long  exposures.  In  the  author's  opinion,  the  great- 
est disadvantage  is  the  long  time  with  its  greater  pos- 
sibilities for  movement.  On  the  other  hand,  the  great 
wealth  of  detail  that  can  be  secured  if  quiet  is  main- 
tained is  very  pleasing.  By  this  method  all  parts  are 
measured,  a  certain  time  being  allowed  each  centimeter. 
With  the  ordinary  exposure  table  one  is  told  to  give  a 
certain  amount  of  time  to  a  knee  in  an  adult  weighing 
approximately  160  pounds.  It  is  well  known  that  knees 
in  160  pound  men  vary,  and  the  roentgenologist  must  use 
his  own  judgment;  that  is,  a  little  less  time  must  be 


POSITIONS  AND   EXPOSURES  101 

given  in  the  case  of  a  tall,  thin  man,  and  a  little  more 
for  a  short  stout  man.  By  using  the  Kuegle  method  this 
personal  element  is  done  away  with,  there  is  a  set  time 
for  each  part. 

The  following  is  submitted  as  approximately  correct 
in  using  both  Paragon  and  Cramer  plates: 

ALL  BONE  WORK 


Centimeters  in  thickness 

Time,  in 

seconds 

Paragon 

Cramer 

4 

% 

1 

5 

1 

1% 

6 

1V4 

2% 

7 

1% 

3 

8 

21/4 

4 

9 

3 

5 

10 

4 

6 

11 

5V2 

7% 

12 

7 

s% 

13 

8 

9% 

14 

9 

11 

15 

10 

121/0 

16 

11 

14 

17 

12 

14% 

18 

13 

16 

19 

14 

17V2 

20 

15 

19 

21 

16 

20i/2 

22 

17 

22 

23 

18 

23% 

24 

19 

25 

25 

20 

20 

26 

21 

27 

Milliamperes,  20. 
Spark  gap,  5^  inches. 
Distance,  24  inches. 


GASTROINTESTINAL  TRACT  (ONLY) 


Time,  in  seconds 


Paragon  Cramer 

(Without  screen)  (Screen) 

Small    (prone)  %  14 

Medium   (prone)  %  % 

Large  (prone)  1%  1/2 

Milliamperes,  65-70. 
Spark  gap,  6i4-6i/£  inches. 
Distance,  24  inches. 


102  ROEXTGEN    TECHNIC 

CHEST  (ONLY) 

Time,  in  seconds 

Paragon         ,  Cramer 

(Without  screen)      (Without  screen) 

Small  1/2  % 

Medium  %  1 

Large  1  l1/^ 

Milliamperes,  80. 
Spark  gap,  Sty-Sty  inches. 
Distance,  30  inches. 


CHAPTER  VI 

SINUS  INJECTION 

Sometimes  it  is  desirable  to  determine  tlie  course  and 
origin  of  a  sinus,  usually  leading  from  some  focus  in  a 
bone,  as  possibly  an  old  bone  abscess  with  sequestrum 
formation,  an  old  Pott's  disease,  or  tuberculosis  of  the 
sacroiliac  joint,  a  discharging  'pulmonary  empyema,  or 
even  an  unremoved  bullet  or  other  foreign  substance. 
AVlien  this  procedure  seems  necessary,  the  sinus  is  in- 
jected with  Beck's  bismuth  paste  which  is  put  up  by 
Parke,  Davis  &  Company.  It  comes  in  collapsible  tubes 
with  a  cap  having  a  long  snout.  This  is  inserted  in  the 
sinus  opening  and  held  firmly  by  a  wad  of  cotton  about 
the  opening.  An  assistant  now  makes  pressure  on  the 
tube,  injecting  as  much  as  the  patient  can  stand  com- 
fortably or  until  it  begins  to  come  out  around  the  cotton. 
A  small  piece  of  adhesive  plaster  with  a  lead  marker  in 
its  center  is  now  pasted  over  the  opening  not  only  to  lo- 
cate the  opening  on  the  plate  but  also  to  stop  the  bis- 
muth from  coming  out  during  the  rest  of  the  procedure. 
Stereoscopic  plates  are  now  taken  which,  when  placed 
in  the  stereoscope,  will  show  the  entire  tract  from  one 
end  to  the  other.  Doctor  Beck,  in  a  recent  article  deal- 
ing with  this  subject,  called  attention  to  the  importance 
of  placing  the  bismuth  injection  container  in  a  hot  water 
bath  before  injecting  so  as  to  insure  its  easy  accessibility 
into  all  recesses  and  cavities  of  the  tract. 


103 


CHAPTER  VII 

LOCATION  OF  FOREIGN  BODIES 

There  have  been  innumerable  methods  and  devices 
recommended  for  the  localization  of  foreign  bodies,  all 
of  which  in  their  place  are  good.  Only  two  will  be  de- 
scribed here  as  they  are  perfectly  adequate  and  require 
no  additional  apparatus.  When  one  can  take  plates  in 
two  directions  as  in  a  forearm  or  ankle>  it  is  hardly  nec- 
essary to  look  further;  stereoscopic  plates  are  also  very 
satisfactory,  but  to  be  a  little  more  accurate,  both  of  the 
following  methods  should  be  used,  one  to  check  the  other. 

Plate  Method 

It  is  well  always  to  fluoroscope  the  part  first  to  get 
some  idea  of  the  location  of  the  foreign  body;  one  is 
sometimes  greatly  surprised  to  find  it  many  inches  from 
its  suspected  location.  This  region  is  then  placed  over 
a  plate  of  adequate  size.  The  tube  is  set  as  for  taking 
a  stereoscopic  set  of  plates,  and  the  first  exposure  made. 
The  tube  is  then  moved  as  in  the  stereoscopic  method 
(2l/2  inches)  without  tilting,  however,  and  the  plate  re- 
maining in  the  same  position,  another  exposure  is  made 
as  before.  It  will  be  seen  on  developing  the  plate  that 
the  object  sought  shows  in  two  different  positions,  caused 
by  the  moving  of  the  tube.  It  is  now  comparatively  easy 
to  figure  geometrically  the  distance  of  the  object  from 
the  plate.  (See  Fig.  54.)  The  distance  from  the  anode 
to  the  plate  is  known,  say  18  inches,  and  is  represented 
by  BC.  The  distance  from  DG  is  known,  2y2  inches. 

104 


LOCATION   OF   FOREIGN   BODIES 


105 


Fig.   54. 

The  distance  between  the  objects  at  the  different  ex- 
posures is  measured,  and  found  to  be  y2  inch  and  is  rep- 
resented by  the  line  EF;  thus  the  formula, 

Let  X  equal  the  distance  of  the  foreign  body  from  the  plate, 

it  being  represented  by  A. 
Let  X  equal  EC  X  EF 
DG  +  EF 

X    will    equal    BC(18")    X    EF(.5)    or    9" 
DG(2.5")    4-    EF(.5)    or    3" 
X  equals  9   or  3" 

3- 
A  is  3"  from  C,  or  the  plate. 


!()()  ROENTGEN   TECHNIC 

The  Fluoroscope  Method 

Tliis  method  is  practically  the  same  as  the  preceding, 
using  the  fiuoroscope  instead  of  the  plate.  The  horizon- 
tal apparatus  is  used.  The  distance  from  the  anode  to 
the  surface  of  the  table  is  known,  say  18  inches.  When 
the  member  in  question  has  been  placed  on  the  table  and 
the  screen  put  in  position,  the  distance  from  the  table  to 
the  screen  surface  is  obtained  by  means  of  a  rule  kept 
near  by.  This  is  added  to  the  already  known  18  inches 
which  gives  the  total  distance  from  the  anode  to  the 
screen.  The  tube  box  is  now  moved  so  that  the  anode 
will  be  exactly  under  the  object  to  be  located,  it  having 
already  been  located  and  diaphragmed  down  upon.  A 
mark  should  now  be  made  with  a  blue  pencil  on  the 
screen  and  also  on  the  flesh  (for  further  reference).  The 
tube  is  now  moved  a  known  distance  one  way  from  the 
vertical,  say  4  inches.  This,  of  course,  must  be  absolutely 
known,  and  can  be  determined  by  notches  cut  in  the  side 
of  the  table  or  by  large  brass  headed  tacks  being  driven 
about  2  inches  apart.  After  the  tube  is  thus  moved  it 
will  be  seen  that  the  object  is  observed  in  a  different 
location  on  the  screen  and  this  new  spot  is  now  marked. 
All  that  has  to  be  done  now  is  to  measure  between  the 
two  marks  on  the  screen  and  the  same  problem  presents 
itself  as  in  the  plate  method. 


The  main  requisite  of  a  dark  room  is  absolute  dark- 
ness. No  ray  of  light,  even  the  smallest,  can  enter  with- 
out jeopardizing  results.  The  room  should  be  of  goodly 
size,  anywhere  from  6  by  8  to  10  by  12  feet.  A  shelf 
should  extend  all  the  way  around  with  the  exception  of 
the  doorway  and  the  sink  or  developing  tank  if  there  be 
one.  The  shelves  may  extend  at  varying  distances  all 
the  way  up  to  the  ceiling,  thus  affording  a  great  deal  of 
storage  space.  On  the  side  or  sides  which  will  be  ex- 
posed to  the  x-ra.ys  there  should  be  placed  1/16  inch  lead 
sheets,  extending  from  the  floor  up  six  feet.  This  is  to 
protect  unexposed  and  developing  plates  from  becoming 
fogged.  The  main  shelf  running  all  the  way  around  the 
room  is  placed  about  32  inches  from  the  floor.  It  should 
be  about  18  inches  deep.  About  6  inches  under  this  shelf 
there  is  placed  another  one  the  same  width.  On  the  de- 
veloping side  this  is  used  to  place  the  pans  when  not  in 
use  and  on  the  loading  side  it  is  utilized  for  empty  en- 
velopes. Underneath  this  shelf  on  the  loading  side,  a 
series  of  compartments  is  built  (Fig.  55)  for  storing  a 
daily  or  weekly  supply  of  plates,  and  also  space  is  left 
for  the  cassetted  screens  so  that  they  may  stand  on  end. 
Underneath  the  developing  shelf,  if  tray  developing  is 
used,  is  a  titubator  or  tray  rocker.  This  is  a  very  neces- 
sary article  when  this  method  is  in  use  and  should  never 
be  omitted.  In  using  this  method  which,  of  course,  neces- 
sitates a  sink,  a  small  overflow  box  should  also  be  used; 
this  not  only  allows  fresh  water  for  the  hands  (the  water 
in  the  sink  being  more  or  less  contaminated  with  hypo), 
but  it  prevents  scratching  plates  that  are  already  in  the 

107 


108 


ROENTGEN   TECHNIC 


sink  washing.  If  more  than  six  plates  a  day  are  to  be 
used,  a  tank  system  should  be  installed.  This  is  very 
convenient  and  has  many  advantages.  A  very  good  one 
on  the  market  measures  about  41  to  251/X>  inches  by  23V2 
inches,  and  can  be  had  with  five  or  seven  compartments. 
It  is  necessary  that  they  be  manufactured  from  some 
substance  of  a  nonmetallic  nature  as  the  chemical  solu- 
tions used  act  on  the  metal  to  the  detriment  of  both. 
Soapstone  is  most  generally  employed.  Plate  holders 


Fig.    55. — Plate,   cassette  and  envelope   rack  under  shelf  in  dark   room. 

come  with  the  tank.  When  the  exposed  plate  is  once 
taken  from  the  envelope  and  placed  in  the  holder,  it  is 
not  necessary  to  put  the  hands  into  any  of  the  solutions 
or  even  the  water. 

The  room  should  be  painted  a  dull  black  or  dull  dark 
red.  It  is  very  convenient,  although  not  absolutely  nec- 
essary, to  have  double  doors  or  a  winding  entrance  lead- 
ing into  this  room.  This  allows  the  operator  to  go  in 
and  out  at  will  while  plates  are  developing  or  exposed 
in  any  other  way,  otherwise  he  will  be  compelled  to  stay 
in  until  everything  is  so  that  the  door  can  be  safely 


DARK   ROOM   PROCEDURES 


109 


opened  and  white  light  admitted.  A  dark  room  to  be 
successful  should  be  well  ventilated  not  only  for  the  sat- 
isfactory drying  of  the  plates  but  also  to  be  hygienic. 


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Fig.  56. — Ventilating  shafts  in  dark  room  walls. 

This  is  easily  accomplished  by  having  openings  on  two 
opposite  sides  of  the  room,  one  above  the  other  so  that 
a  free  circulation  can  take  place.  If  the  walls  have  been 


110  ROENTGEX  TECHNIC 

built  specially  and  are  composed  of  tile  and  plaster,  the 
boxes  used  will  be  placed  in  the  tile,  but  if  only  a  parti- 
tion is  employed,  they  will  have  to  be  put  on  one  side 
or  another.  (See  Fig.  56.) 

Plate  Loading 

All  plates  should  be  placed  in  envelopes  before  being 
taken  from  the  dark  room  to  protect  them  from  the  day- 
light which,  of  course,  would  ruin  them  by  fogging. 
Black  and  orange  envelopes  come  with  all  plates  and 
should  be  placed  upon  the  plate  in  the  following  manner: 
The  film  side  of  the  plate  should  be  determined,  either 
by  means  of  a  very  dim  ruby  light,  or  by  wetting  the 
thumb  and  first  finger  and  pressing  them  over  one  cor- 
ner; due  to  the  gelatine  on  the  film  side,  it  will  be  sticky, 
whereas  the  glass  side  will  not.  The  plate  is  now  bal- 
anced upon  the  first  two  fingers  held  with  the  thumb  on 
the  top,  the  film  being  uppermost.  The  black  envelope 
is  now  taken  in  the  other  hand  with  the  flap  side  up  and 
slipped  over  the  far  end  of  the  plate,  the  thumb  holding 
the  flap  out  of  the  way.  The  plate  is  now  easily  slipped 
in,  the  thumb  still  holding  the  flap  away  from  the  film, 
for  if  the  flap  is  allowed  to  drag  along  the  film,  it  may 
not  only  scratch  it,  but  it  is  held  that  due  to  friction 
what  is  known  as  static  electricity  is  produced  which 
causes  a  slight  fog.  After  the  plate  is  well  in,  the  flap 
is  turned  down  and  this  envelope  together  with  its  en- 
closed plate  is  slipped  into  the  orange  envelope,  flap  end 
first,  being  sure  to  have  the  flap  side  of  the  black  envelope 
enter  the  flap  side  of  the  orange  envelope;  this  brings 
the  film  side  of  the  plate  against  the  smooth  or  flap  side 
of  the  orange  envelope  and  should  be  placed  next  the 
patient's  skin.  If  this  rule  is  invariably  followed,  one 
can  always  state  positively  just  how  the  plate  lay  when 


DARK  ROOM  PROCEDURES  111 

the  exposure  was  made,  and  thereby  avoid  embarrass- 
ment in  sometimes  not  being  able  to  state  which  side  of 
the  body  has  been  taken. 

Plate  Protection 

All  plates  not  protected  by  the  lead  lined  dark  room 
should  be  placed  in  a  metallic  covered  box,  preferably 
lead.  This  is  usually  kept  in  or  near  the  roentgeno- 
graphic  room  so  that  in  taking  several  plates,  one  will 
not  have  to  run  back  and  forth  to  the  dark  room  between 
exposures,  but  can  place  the  exposed  plate  in  one  end  of 
the  box,  taking  a  fresh  one  from  the  other  end.  A  plate 
not  protected  in  some  manner  even  at  a  great  distance 
will  be  ruined  if  the  tube  is  excited. 

Development 

Formulas  for  the  development  of  different  makes  of 
plates  are  enclosed  in  each  box,  and  it  is  advisable  that 
one  of  several  recommended  be  used  for  that  particular 
plate,  for  it  only  stands  to  reason  that  the  photographic 
chemists  who  make  the  emulsions  are  in  a  better  position 
to  know  what  developing  agents  should  be  used,  and  the 
amount,  than  another  not  so  well  acquainted  with  the 
facts.  The  following  are  some  of  the  more  common  de- 
velopers and  are  satisfactorily  used  with  the  average 
domestic  plate. 

All  photographic  chemicals  should  be  weighed  by  the 
avoirdupois  scale  only. 

DEVELOPERS 
Solution  1. — 

A.    Water  32  oz. 

Hydrochinone  1^  oz. 

Sodium  sulphite  1  oz. 

Sulphuric  acid  60  minims. 


112  ROENTGEN   TECHNIC 

B.    Water  32  oz. 

Sodium  carbonate  1  oz. 

Potassium  carbonate  3  oz. 

Potassium  bromide  120  gr. 

Sodium  sulphite  3  oz. 
Use  equal  parts  of  A  and  B. 

Solution  2  — 

A.  Water  1  gal. 
Metol  1A  oz. 
Hydrochinone  4  oz. 
Sodium  sulphite  1%  oz. 

B.  Water  1  gal. 
Sodium  sulphite  7l/2  oz. 
Potassium  carbonate  5  oz. 
Potassium  bromide  %  oz. 

Use  equal  parts  of  A  and  B. 

Solution  3. — 

A.  Water  32  oz. 
Sodium  sulphite  6  oz. 
Hydrochinone  1  oz. 
Edinol  5  dr. 
Potassium  bromide  6  dr. 

B.  Water  32  oz. 
Potassium  carbonate  8  oz. 

Use  one  ounce  A,  one  ounce  B,  and  two 
ounces  water. 

Solution  4  — 

A.    Water  32  oz. 

Sodium  sulphite  6  oz. 

Hydrochinone  1  oz. 

Edinol  4  dr. 

Potassium  bromide  6  dr. 


DARK   ROOM  PROCEDURES  113 

B.     Water  32  oz. 

Sodium  carbonate  7  oz. 

Use  one  ounce  A,  one  ounce  B,  and  two 
ounces  water. 

Solution  o.— 

Water  20  oz. 

Metol  20  gr. 

Hydrocliinone  80  gr. 

Sodium  carbonate  1  oz. 

Sodium  sulphite  1  oz. 

Potassium  bromide  10  gr. 

Solution  6. — 

A.  Hot  water  40  oz. 
Sodium  sulphite  7  oz. 
Potassium  carbonate  14  oz. 

(Dissolve  and  add  B.) 

B.  Adurol  2  oz. 
Metol  120  gr. 
Potassium  bromide  120  gr. 

Use  one  part  solution  to  three  parts  water. 

FIXIXG  BATH 

A.  Hyposulphite  of  soda  (pea 

crystals)  4  Ib. 

Water  120  oz. 

B.  Water  70  oz. 
Chrome  alum  4  oz. 
Sodium  sulphite  8  oz. 

C.  Water  10  oz. 
Strong  sulphuric  acid  J/2  oz. 

After  all  solutions  are  wrell  dissolved,  pour  C 
into  B  and  this  then  into  A.  When  solution 
CB  is  poured  into  A,  the  latter  should  be 
agitated.  This  will  insure  a  clear  solution 
free  from  sediment. 


114  ROENTGEN   TECHNIC 

After  the  plate  has  been  exposed  and  taken  to  the  dark 
room  and  the  envelopes  removed,  the  patient 's  name  and 
the  date  should  be  written  in  the  upper  right-hand  cor- 
ner (when  using  numbers  with  plate  markers  this  will 
be  unnecessary).  The  tray  should  be  filled  with  solu- 
tion at  least  ^  inch  deep  and  wThen  putting  the  plate 
in,  it  is  well  to  tip  the  tray  away  from  one,  slip  the 
plate  in  and  quickly  tip  the  far  side  upward.  This  im- 
mediately causes  an  even  flow  of  solution  over  the  en- 
tire plate  which  is  very  essential  for  if  one  part  is  not 
covered  as  soon  as  the  rest  and  remains  so  even  for 
only  a  few  seconds,  it  will  be  behind  in  the  development 
and  can  never  catch  up.  This  will  cause  this  part  to  be 
lighter  than  the  rest  of  the  plate.  After  the  plate  is 
entirely  covered,  it  is  necessary  to  rock  it  gently  to 
and  fro  both  lengthwise  and  sidewise  until  development 
is  complete.  This  not  only  dissipates  any  air  bubbles 
that  may  be  in  the  solution  and  which  obviously  would 
retard  development  if  allowed  to  remain  standing  in  one 
place,  but  it  also  keeps  the  very  small  particles  of  un- 
dissolved  chemicals  from  settling  on  the  plate  and  there- 
by causing  a  more  or  less  mottled  effect  on  the  film.  If 
a  titubator  is  used  after  the  plate  is  once  in  the  solu- 
tion, the  action  of  the  rocker  keeps  the  solution  in  mo- 
tion. With  tank  development  after  removing  the  plate 
from  the  envelope  it  is  placed  in  the  holder  and  dropped 
in  the  solution  where  it  remains  quiet  on  edge  until  de- 
velopment is  complete.  It  is  very  essential  that  the  dark 
room  and  the  developing  solution  be  maintained  at  a 
given  temperature,  say  between  65°  and  70°  F.  A  solu- 
tion used  when  taken  from  a  cold  room  will  develop 
very  slowly  and  show  a  minimum  of  density.  This  is 
due  to  the  fact  that  the  hydrochinone,  which  is  a  part 
of  practically  all  solutions,  acts  very  slowly  at  a  tem- 
perature of  65°,  and  below  that  becomes  almost  inert. 
If,  on  the  other  hand,  the  solution  is  too  warm,  a  plate 


DARK   ROOM   PROCEDURES  115 

with  a  muddy  and  foggy  appearance  will  result.  Where 
the  solutions  are  kept  in  the  dark  room,  which  is  the 
usual  custom,  all  that  is  necessary  is  to  keep  the  room 
temperature  at  the  proper  point  and  the  solutions  will 
be  correct.  In  the  hot  weather  a  fan  does  very  nicely 
and  in  the  winter  season  a  small  electric  stove  properly 
protected  so  as  to  exclude  all  light  and  turned  on  when 
the  temperature  requires  solves  the  problem  adequately. 
A  point  may  be  mentioned  here  that  is  sometimes  passed 
over  lightly  by  some  workers,  but  which  is  of  the  utmost 
importance,  and  that  is,  precaution  should  be  exercised 
to  keep  hypo  out  of  the  developing  solution.  It  does  not 
seem  reasonable  or  possible,  but  if  even  so  small  an 
amount  as  a  few  drops  gets  into  a  batch  of  developer  it 
will  be  ruined.  If  skepticism  exists,  try  it  with  two 
plates  taken  under  like  conditions  before  and  after  the 
addition  is  made.  If  one  will  make  it  a  habit  to  dip  the 
hands  in  running  water  after  having  them  in  any  solu- 
tion and  drying  them  lightly,  trouble  will  be  avoided. 

Different  plates  develop  out  differently.  The  three 
domestic  plates  used  most  commonly  in  the  average  lab- 
oratory are  Paragon,  Seed's  and  Cramer's.  As  the  reader 
will  probably  use  one  or  the  other,  no  other  makes  will 
be  taken  up  here. 

Paragon  Plate. — This  is  a  very  heavily  coated  plate 
holding  an  extra  amount  of  silver  in  the  emulsion.  As 
it  develops  the  image  will  be  seen  to  come  up  and  if 
viewed  on  the  glass  side,  will  be  seen  to  be  coming 
through,  showing  that  the  image  is  reaching  through 
the  entire  thickness  of  the  film.  It  will  be  noted  when 
development  has  reached  its  height  that  the  image  on 
the  film  side  is  now  beginning  to  fade  somew^hat,  that 
is,  becoming  less  distinct.  If  the  plate  is  now  held  up 
to  the  red  light,  it  will  be  found  to  be  dense  or  black, 
no  light  from  the  ruby  coming  through.  It  is  now  ready 
for  the  hypo,  but  before  placing  it  in  the  hypo,  hold  it 


116  ROENTGEN   TECHNIC 

on  edge  and  let  it  drain  so  as  to  conserve  the  solution. 
Now  rinse  it  in  the  wash  for  at  least  one  minute.  (A 
hurried  washing  that  allows  some  of  the  developer  to  be 
carried  into  the  hypo  solution  will  not  only  bring  forth 
dirty  looking  plates  but  will  very  shortly  ruin  the  hypo. 
This  is  very  important.)  It  is  then  placed  in  the  hypo 
where  it  should  remain  five  minutes  after  all  the  milki- 
ness  has  disappeared  as  viewed  from  the  glass  side. 
It  is  now  ready  for  the  washing  bath  where  it  should 
remain  for  at  least  a  half  hour  under  constantly  chang- 
ing water.  After  this,  it  is  taken  out  and  the  film  mopped 
over  with  a  good  sized  piece  of  absorbent  cotton,  care 
being  taken  not  to  rub  the  finger  nails  over  the  emul- 
sion, for  scratches  will  ruin  the  plate.  The  plate  is  next 
stood  on  its  edge  in  the  drying  rack  where  it  is  allowed 
to  remain  until  dry  which  will  consume  from  6  to  8 
hours,  depending  on  the  temperature  and  circulation  of 
the  air. 

Cramer  Plate. — The  image  appears  on  the  film  and 
glass  side  the  same  as  with  the  Paragon,  but  if  properly 
exposed,  the  plate  will  not  become  dense  to  the  red  light, 
even  when  fully  developed,  the  details  of  the  image  show- 
ing well,  even  when  finished  and  viewed  by  the  dark 
room  lamp.  When  the  image  on  the  glass  side  shows 
even  more  clearly  than  on  the  film  side  then  the  plate  is 
ready  for  the  washing  and  hypo. 

Seed  Plate. — This  plate  can  be  said  to  be  about  mid- 
way between  the  Paragon  and  the  Cramer  as  far  as  de- 
veloping is  concerned.  When  fully  developed,  the  ruby 
will  show  through  very  indistinctly,  no  image  being  dis- 
cernible. Its  film  is  heavy  but  firmer  than  the  Para- 
gon, having  more  of  the  Cramer  hardness.  When  using 
any  plate  with  an  intensifying  screen,  the  image  will  not 
come  through  on  the  reverse  side  as  it  does  otherwise. 


DARK  ROOM  PROCEDURES  117 

Printing  from  X-Ray  Negatives 

Printing  from  x-ray  negatives  has  to  be  done  occa- 
sionally. It  is,  however,  a  bad  plan  to  make  a  practice 
of  giving  out  too  many  prints.  In  certain  insurance 
cases,  etc.,  they  will  have  to  be  made,  but  giving  prints 
to  patients  promiscuously  is  to  be  strongly  condemned. 
Eventually  it  will  lead  to  trouble  for  the  roentgenologist, 
referring  physician,  or  some  other  party  concerned. 
When  prints  are  made,  the  following  technic  is  to  be 
used  : 

A  40  watt  tungsten  lamp  is  placed  above  the  work 
shelf.  Its  height  depending  on  the  size  of  the  print  to 
be  made.  The  rule  is  that  the  height  should  be  the  same 
from  the  center  of  the  plate  as  the  diagonal  distance  from 
corner  to  corner;  thus,  for  a 


5x7 

8^2  inches 

l/2x81/2 

10%  inches 

8x10 

12%  inches 

11x14 

17%  inches 

14x17 

221/4  inches 

There  should  be  an  old  14  by  17  plate  that  has  been 
discarded  kept  in  the  dark  room  for  just  this  work.  It 
should  be  placed  on  the  work  shelf  so  that  an  absolutely 
level  surface  will  be  had  on  which  to  work,  or  print- 
ing can  not  be  done  successfully.  The  lights  are  now  all 
extinguished  except  the  ruby,  and  the  paper  is  placed 
with  the  shiny  or  film  side  upward,  the  plate  being  placed 
with  the  film  down,  bringing  film  to  film.  Sometimes  this 
is  not  possible  as  it  will  reverse  the  image  and  make  some 
confusion.  Suffice  it  to  say  the  image  should  be  repro- 
duced on  the  paper  as  it  would  be  shown  if  the  plate  was 
exhibited.  If  film  is  to  film,  any  movement  of  the  light 
makes  no  difference  but  if  the  film  of  the  plate  is  upper- 
most, then  the  light  must  be  kept  absolutely  still,  espe- 


118  EOENTGEN  TECHNIC 

cially  if  the  glass  is  a  little  thick,  or  the  printed  image 
will  not  be  clear  cut.  The  time  of  exposure  will  vary 
greatly  with  the  paper  used  and  even  with  one  paper  a 
great  variance  results  from  the  different  densities  of  the 
plates.  The  author  has  used  one  paper  more  than  any 
other  and  finds  it  very  satisfactory;  namely,  Cyko-Con- 
trast-Glossy,  put  out  by  the  Ansco  Company,  of  Bing- 
hamton,  New  York.  This  is  not  inferring  that  other  pa- 
pers are  not  good,  for  the  author  knows  of  quite  a  num- 
ber that  give  excellent  results  in  this  particular  work. 
However,  whatever  paper  is  used,  a  glossy  finish  of  the 
contrast  variety  must  be  insisted  upon,  as  softer  papers 
such  as  Normal,  Soft,  Professional,  and  others  give  more 
of  the  hazy  mild  blending  effect  so  desired  in  landscape 
and  portrait  work,  but  which  is  absolutely  prohibited  in 
roentgenographic  use  where  contrast  is  so  much  desired. 
With  the  above  mentioned  paper,  an  exposure  of  from 
10  seconds  to  5  minutes  is  required,  the  average  being 
about  45  seconds,  but  no  fast  rule  can  be  laid  down  as 
every  one  must  work  it  out  for  himself.  A  trial  of  a  few 
prints  from  a  dozen  plates  will  give  a  good  idea  of  time 
required.  After  the  exposure,  the  plate  is  set  aside  and 
the  developing  solution  (which  has  previously  been 
mixed  and  set  to  one  side)  is  placed  on  the  shelf.  As  a 
routine,  this  solution  consists  of  one  of  the  ordinary 
M.  &  Q.  mixtures  which  come  put  up  in  tubes  and  offered 
by  the  various  manufacturers.  Some  of  these  vary,  but 
most  of  them  call  for  a  diluent  of  8  oz.  of  water.  The 
tube  is  separated  into  an  upper  and  lower  half,  the  former 
of  which  is  put  into  the  water  and  dissolved,  followed  by 
the  latter.  If  this  quantity  is  not  enough  to  cover  well 
the  bottom  of  the  tray,  it  will  have  to  be  doubled.  This 
solution  will  not  keep  well  and  should  be  discarded  as 
soon  as  printing  is  finished. 

The  paper  is  taken  in  the  hand  in  such  a  manner  that 
it  is  held  stiff,  the  tray  is  now  sloped  sharply  to  the  op- 


DARK  ROOM  PROCEDURES  119 

posite  side  from  which  the  paper  is  held,  bringing  all  the 
solution  well  to  that  side.  The  paper  is  now  quickly 
thrust  into  the  tray  and  the  solution  run  over  it  by  tilt- 
ing the  tray  quickly  to  the  other  side.  This  is  very  im- 
portant and  must  be  done  as  rapidly  as  possible  as  the 
development  starts  almost  immediately  and  if  the  paper 
is  not  covered  at  once  a  light  spot  is  left.  The  tray  must 
now  be  rocked  rapidly  to  and  fro.  Some  workers  prefer 
to  put  the  paper  in  with  the  film  down,  running  the  fin- 
gers over  it  hurriedly  so  that  it  is  all  submerged  im- 
mediately. It  is  then  turned  over  and  rocked  as  usual. 
The  print  will  begin  showing  and  will  be  finished  in  from 
10  seconds  to  45  seconds.  It  is  then  quickly  run  through 
the  water  once  or  twice  and  placed  in  the  hypo  or  fixing 
bath,  face  downward,  for  a  few  minutes.  Washing  fol- 
lows which  should  continue  for  10  or  15  minutes.  The 
print  is  now  squeegeed;  that  is,  all  the  water  possible 
pressed  out  of  it.  This  is  done  as  follows: 

A  metal  sheet  about  18  inches  square  called  a  ferro- 
type board,  composed  of  japanned  sheet  iron,  is  kept 
handy.  When  used,  this  is  covered  by  a  mixture  of  bees- 
wax and  benzine,  about  %  ounce  of  wax  in  8  ounces  of 
oil.  Before  using,  shake  well  and  pour  on  a  small  quan- 
tity, a  dry  cloth  being  used  to  spread  it  over  the  board. 
It  is  rubbed  with  a  rotary  polishing  action  until  the 
ferrotype  shines  with  a  good  luster.  The  print  is  now 
removed  from  the  water,  mopped  off  with  a  piece  of  cot- 
ton and  placed  face  downward  on  the  metal.  A  rubber 
roller  being  used  to  squeegee  out  all  the  water  and  make 
it  adhere  evenly  at  all  points.  When  dry  it  will  be  com- 
paratively flat  and  have  a  fine  luster,  due  largely  to  the 
wax.  (See  Fig.  57.) 

In  printing,  one  sometimes  has  to  dodge  in  order  to 
bring  out  the  whole  object.  This  is  a  procedure  whereby 
a  part  of  the  negative  is  covered  and  thereby  held  back 


120 


ROENTGEN  TECHNIC 


while  printing  is  going  on  so  another  part  of  the  plate 
may  get  more  light  effect,  due  of  course  to  one  part  which 
is  thinner,  getting  more  exposure  than  an  adjacent  thick 
part.  If,  for  instance,  one  takes  an  anteroposterior  view 
of  a  foot,  in  getting  through  the  tarsus,  the  metatarsals 
and  phalanges  will  be  overexposed  or  at  least  are  denser 
to  the  light  than  the  thicker  tarsus.  In  printing  if  time 


Fig.    57. — A  print  drying  on  a  ferrotype   after   squeegeeing. 

enough  only  is  given  for  the  tarsus,  the  metatarsals  will 
not  show  on  account  of  their  denseness,  but  if  time  enough 
is  given  to  cut  through  the  toes,  the  tarsus  will  be  so 
black  that  nothing  can  be  distinguished,  therefore  the 
tarsus  is  dodged.  The  light  is  turned  on  as  usual,  and 
when  the  tarsus  has  had  about  half  as  much  as  one  would 
think  necessary,  a  paper,  envelope  or  anything  more  or 
less  stiff  is  held  about  one-half  inch  away  from  the  light 


DARK   ROOM   PROCEDURES  121 

tarsal  area.  It  should  not  be  allowed  to  stay  quiet  long 
as  its  impression  will  take  on  the  paper.  Move  it  back- 
ward and  forward  with  a  quick  motion  until  time  enough 
has  been  given  for  the  toes.  Even  with  this  shade  some 
light  comes  in  and  probably  the  tarsus  will  have  had 
enough  by  the  time  the  toes  are  done.  It  may  take  sev- 
eral trials  to  get  a  good  print,  but  if  an  accurate  time 
record  is  kept  of  the  exposure  for  the  different  parts  so 
that  at  the  next  trial  they  can  be  increased  or  diminished 
as  necessary,  finally  a  good  print  will  be  obtained. 

Lantern  Slides 

Apparatus  Required,  and  Procedure. — A  plate  camera 
capable  of  holding  G^xS^  plates  is  almost  indispensable 
although  one  can  get  along  with  a  4x5.  The  plate  holders 
are  fitted  with  what  is  known  as  kits,  so  that  different 
sized  plates  can  be  used;  thus,  one  may  use  a  variety 
of  sizes  as  the  occasion  may  arise,  which  will  be  very 
often.  The  most  common  sizes  used  will  be  a  4x5  and 
the  lantern  slide  size  314X4.  An  illuminating  box 
equipped  with  an  indirect  lighting  system  is  required. 
This  is  best  made  by  utilizing  one  of  the  old  style  il- 
luminating boxes,  the  inside  being  well  coated  with  white 
enamel,  and  reflectors,  being  placed  on  all  four  sides  so 
as  to  throw  the  light  to  the  back  of  the  box,  nitrogen 
lamps  being  concealed  behind  the  reflectors,  one  in  each 
corner  and  one  in  the  center  of  each  reflector  midway 
from  each  corner.  The  four  corner  ones  are  wired  so  as 
to  turn  on  all  at  once,  and  the  ones  in  between,  one  at  a 
time  if  desired.  The  box  and  the  camera  are  set  on  an 
inch  board,  6  inches  wide  and  8  feet  long  with  iron  strips 
on  each  side  to  prevent  sagging,  the  whole  being  held 
up  by  legs  on  each  end.  The  box  is  fastened  permanently 
at  one  end  in  such  a  way  that  the  glass  front  is  exactly 


122 


ROENTGEN  TECHNIC 


DARK   ROOM  PROCEDURES 


123 


perpendicular.  Extending  from  the  other  end  up  to  with- 
in 2  feet  of  the  box  is  a  slit  *4  inch  wide  extending  all 
the  way  through  the  board.  A  platform  device  is  now 
used  which  sets  over  this  slit  and  which  supports  the 
camera,  it  being  equipped  with  screws  the  same  as  are 
found  on  the  tripod  to  attach  it  to  the  camera,  one  to 
attach  the  camera  to  the  platform  and  the  other  to  make 


Fig.   59. — Rear  of  camera  showing  centering  squares  on  ground  glass. 

the  whole  (camera  and  platform)  solid  on  the  plank  so 
that  no  movement  will  take  place  while  manipulating 
plate  holders.  (See  Fig.  58.)  The  opening  in  the  box 
is  now  made  to  fit  the  size  plate  to  be  reproduced.  The 
small  kit  is  placed  in  the  plate  holder  and  with  only  the 
ruby  light  lit  in  the  dark  room,  a  lantern  slide  is  in- 
serted, the  film  side  being  placed  out  or  toward  the  light. 
There  are  many  good  brands  of  slides  on  the  market. 
The  author  in  his  work  has  adopted  the  Standard  Slow, 


124 


ROENTGEN  TECHNIC 


put  out  by  the  Eastman  Kodak  Company,  of  .Rochester, 
N.  Y.,  this  being  a  very  reliable  article.  By  using  the 
slow  variety,  one  has  more  latitude  for  error  than  with 
the  fast.  After  lighting  the  lamps  in  the  box  behind 
the  x-ray  negative  and  opening  the  shutter  in  the  cam- 
era, the  camera  is  moved  backward  and  forward  until 
the  size  of  the  image  on  the  ground  glass  at  the  back  of 
camera  is  a  little  smaller  than  a  slide  (the  ground  glass 


Fig.   60. — Simple  method  of  arrangement  for  making  lantern  slides  from  illustrations. 


should  be  marked  with  a  square  S1/^  by  4  inches,  lantern 
slide  size,  in  the  exact  center,  also  one  4  by  5  inches 
evenly  outside  this  if  this  size  is  to  be  used).  (Fig.  59.) 
Images  must  be  taken  always  with  the  unexposed  slide 
lying  lengthwise  as  this  is  the  only  way  they  will  fit  in 
a  lantern.  After  getting  the  focus,  the  camera  is  locked 
to  the  board  by  the  thumb  screw.  The  shutter  is  now 
closed  and  the  plate  holder  with  slide  in  place  is  inserted, 
the  shutter  opened  and  the  exposure  made.  The  time 


DARK   ROOM   PROCEDURES 


125 


of  exposure  will  vary  according  to  the  distance  of  the 
camera  from  the  negative,  and  also  according  to  the  den- 
sity of  the  negative.  This,  roughly  speaking,  using  the 
slow  slide  will  be  from  y2  to  4  minutes.  Everyone  will 
have  to  work  out  his  own  exposures,  however,  but 
when  once  obtained,  few  spoiled  slides  will  result. 


Fig.  61. — A  negative. 

After  the  exposure,  the  plate  holder  is  closed  and  re- 
moved to  the  dark  room  for  development.  The  original 
plate  made  of  an  object,  whether  it  be  x-ray  or  photo- 
graph, is  called  a  negative.  If  this  is  reproduced  on 
paper  or  another  plate  (as  in  lantern  slide  making),  the 


126 


ROENTGEN   TECHNIC 


copy  becomes  a  positive.  If  a  copy  is  made  from  this 
positive,  a  negative  is  again  produced  and  so  on  indef- 
initely. Some  men  like  their  x-ray  plates  produced  on 
the  slide  as  originally  taken,  that  is,  bone  white  and  sur- 
rounding parts  dark  or  black  as  the  case  may  be.  Of 
course,  positives  will  be  just  the  reverse  of  this.  In  or- 


Fig.   62. — A  positive. 

der  to  produce  a  negative,  the  procedure  as  previously 
outlined,  must  be  gone  through  with  and  after  the  slide 
is  developed  and  dried,  it  is  placed  film  to  film  with  an 
unexposed  slide  (ruby  light  only)  the  developed  plate 
Being  uppermost.  A  40  watt  tungsten  lamp  is  used  about 


DARK  ROOM   PROCEDURES  127 

3  feet  away.  The  exposure  will  vary  from  a  mere  flash 
to  3  or  4  seconds,  an  average  being  about  2  seconds. 
This  depends,  of  course,  upon  the  density  of  the  lantern 
slide  positive.  The  resulting  image  when  developed  will 
be  a  true  likeness  of  the  original  x-ray  plate,  or  a  nega- 
tive. 

If  a  slide  is  to  be  made  from  an  illustration  in  a  book, 
the  camera  must  be  used.  The  book  is  held  firmly  and 
flatly  to  the  wall.  It  is  essential  that  all  parts  of  the  pic- 
ture be  absolutely  flat  or  it  can  not  all  be  brought  into 
focus,  one  part  being  nearer  the  camera  than  another. 
Two  40  watt  nitrogen  lamps  in  reflectors  on  stands  with 
universal  joints  are  placed  on  either  side,  the  -Toom  is 
darkened  and  the  same  technic  is  used  as  in  photograph- 
ing an  x-ray  plate  while  in  the  illuminated  box.  (See 
Fig.  60.)  After  this  has  been  developed,  it  is  a  negative 
(pictures  in  books  are  positives  as  are  any  photographic 
prints)  which,  of  course,  is  unsuitable  for  exhibition  for 
in  this  we  show  the  man's  white  shirt  and  collar  black, 
his  black  necktie  and  coat  white,  etc.,  as  shown  in  Fig. 
61.  Therefore  this  negative  must  be  made  a  positive  by 
contact  the  same  as  has  been  described  for  reproducing 
the  original  colors  in  the  x-ray  plate  (Fig.  62). 

Developing. — There  is  a  formula  for  a  developer  with 
each  box  of  slides  which  is  the  correct  one  to  use  with 
that  particular  brand.  The  formula  for  the  Standard 
slide  is  as  follows: 

A.  Water  16  oz. 
Elon  30  gr. 
Hydrochinone  100  gr. 
Sodium  sulphite  130  gr. 

B.  Water  16  oz. 
Sodium  carbonate  100  gr. 
Potassium  bromide  15  gr. 

Use  equal  parts  of  A  and  B. 


128  ROENTGEN  TECHNIC 

After  once  being  mixed,  the  solution  will  not  keep 
and  must  be  discarded,  a  new  batch  being  made  up  each 
time.  The  slide  is  put  in  the  solution  the  same  as  an 
x-ray  plate,  being  particularly  careful  to  get  the  solu- 
tion to  fully  cover  the  plate  immediately.  The  image 
will  be  seen  to  appear  in  a  few  seconds  and  as  it  gets 
darker,  will  be  found  to  be  coming  through  on  the  glass 
side.  In  no  other  kind  of  plates  handled  in  an  x-ray 
dark  room  is  it  as  necessary  to  have  a  clear  sharp  image 
on  the  glass  side  as  in  lantern  slide  plates.  The  film 
side  can  be  disregarded  as  this  becomes  quite  dark, 
sometimes  even  indistinguishable.  The  whole  develop- 
ing time  will  probably  not  be  over  a  minute,  but  let  the 
time  go  and  watch  the  plate,  and  when  the  image  is 
well  through,  take  it  out.  If  it  is  subsequently  found  to 
be  too  dark,  blame  the  exposure  not  the  development. 
After  removal  from  the  developer,  rinse  well  in  running 
water  and  place  in  the  hypo. 

Disposition  of  Plates 

Plates  should  never  be  allowed  to  leave  the  office  per- 
manently and  not  even  temporarily  unless  it  is  well  un- 
derstood that  they  will  be  returned  in  a  short  time.  They 
are  the  only  absolute  record  that  the  roentgenologist  has, 
and  if  lost  sight  of,  he  is  greatly  handicapped  in  various 
ways.  X-ray  plates  are  very  frequently  of  great  impor- 
tance in  legal  matters.  Instances  may  come  up  in  which 
they  will  be  of  the  utmost  importance,  although  little 
or  nothing  was  considered  at  the  time  of  the  examina- 
tion. They  not  only  materially  affect  financial  matters, 
but  reputations,  professional  ability,  false  accusations, 
and  numerous  other  things  may  in  time  rest  wholly  on 
the  findings  depicted  in  the  roentgenogram.  The  roent- 
genologist is  continually  being  approached  by  patients 


DARK    ROOM    PROCEDURES 


129 


demanding  that  the  plates  be  delivered  to  them,  for  as 
they  say,  "I  paid  for  them."  This  can  be  refuted  as  it 
has  been  done  in  the  courts  many  times,  by  citing  the 
fact  that  the  fee  paid  was  not  for  the  picture  but  for 
the  opinion  the  plate  revealed,  the  plate  being  the  roent- 
genologist's  manner  of  obtaining  his  knowledge  of  the 


l 


X-RAY 
FHVEIOPES. 


Cnunr  Dry  PUK  Ok 


Fig.   63. — Manner   in   which  envelopes  are  marked  for  filing. 

case.  It  is  just  as  reasonable  to  ask  an  internist  for  his 
case  record  of  a  particular  individual,  giving  all  his  find- 
ings, both  physical  and  chemical,  as  to  ask  the  x-ray  spe- 
cialist for  his  record,  the  plate.  When  a  man  forms  the 
habit  of  making  a  " picture"  for  a  patient,  presenting 
him  with  the  negative,  he  will  be  lowering  himself  pro- 


130 


ROENTGEN   TECHNIC 


4 


s 


X 


1 


V 


N 


1 


3) 


Q 


1 


rt 


1 


fc 

U   -J 


DARK    ROOM    PROCEDURES  131 

fessionally,  putting  himself  in  the  class  with  the  photog- 
rapher, so  that  he  need  not  be  surprised  when  he  is  called 
upon  some  day  to  make  an  appointment  for  "a  sitting." 

The  day  following  the  taking  of  a  plate,  the  plate  then 
being  dry,  is  ready  for  filing.  The  number,  date,  and 
position,  if  desired,  is  placed  in  the  upper  right  hand 
corner  on  the  film  side,  using  a  blue  china  pencil  which 
can  be  obtained  in  most  any  stationery  store.  Of  course, 
if  lead  numbers  and  dates  are  used  as  shown  in  Fig.  12, 
no  penciling  will  be  necessary.  If  stereoscopic  plates  are 
taken,  it  is  well  to  number  them  1  and  2,  this  having  al- 
ready been  done  by  pencil  before  development.  They  are 
now  placed  in  filing  envelopes  of  proper  size  and  marked 
ready  for  filing  in  the  cabinet  (Fig.  63).  If  more  than 
one  plate  has  been  used  on  a  particular  case,  file  all  in 
one  envelope  if  of  the  same  size,  but  if  different  sizes, 
put  each  in  a  separate  envelope,  all  of  which  will  be 
placed  in  the  largest  sized  one,  this  being  the  only  one 
that  is  marked  (Fig.  63).  If  all  are  put  in  the  large 
envelope  without  covering,  they  will  soon  become 
scratched  from  rubbing  against  each  other.  A  book  is 
kept  in  which  each  case  is  recorded  as  shown  in  Fig.  64. 

It  will  be  noted  that  each  patient  has  a  new  number 
which  runs  consecutively.  If,  however,  an  old  case  comes 
back  for  a  new  examination,  he  is  entered  in  the  book 
under  his  old  number.  This  allows  the  new  plate  to  be 
filed  in  the  old  envelope.  Each  case  is  given  a  card 
(see  illustration,  page  31)  with  the  number  in  the  upper 
left  hand  corner,  the  name  being  on  the  top  line  near  the 
right.  These  cards  are  filed  alphabetically  in  an  ordinary 
card  index  box.  In  looking  for  the  plates  in  a  given  case, 
the  card  is  found  by  name,  the  number  ascertained  to- 
gether with  the  size  of  the  plate  and  with  this  data  it  is 
easily  located  in  the  plate  file.  Plates  should  be  filed  in 


132 


ROENTGEN   TECHNIC 


the  rack  according  to  size,  all  of  one  size  being  on  fol- 
lowing shelves  in  numerical  order. 

It  is  desirable  to  keep  a  cross  index  of  all  the  case 
cards,  that  is,  file  them  according  to  a  given  classification 
so  that  if  at  any  time  one  cares  to  get  together  all  his 
plates  on  a  certain  subject  he  will  be  enabled  to  do  so 
with  the  least  possible  waste  of  time.  This  classification 
is  a  matter  of  preference.  One  that  is  very  convenient 


HT 7 

1  iC/-ia.- 


Fig.  65. — Cross  index  card.     The  shaded  type  shows  where  red  ink  should  be  used. 

and  a  great  deal  more  simple  than  the  average  is  as 
follows: 

All  the  bones  of  the  body  except  the  head  and  the 
small  bones  of  the  carpus  and  the  tarsus  are  each  given 
a  card,  not  distinguishing  right  from  left.  A  card  is 
also  devoted  to  the  following  "systems,"  gastrointestinal, 
cardiovascular,  urinary,  respiratory,  one  for  foreign 
bodies,  one  for  heads,  accessory  sinuses  (including  mas- 
toid),.and  miscellaneous.  These  cards  are  made  as  shown 
in  Fig.  65,  using  the  ordinary  card  index  size.  The  num- 
ber, name  and  diagnosis  is  put  on  the  card.  When  the 


DARK    ROOM    PROCEDURES  133 

case  is  normal,  it  is  put  in  in  red  ink  (shown  by  shaded 
type  in  Fig.  65).  In  this  way  if  it  is  necessary  to  obtain 
on  short  notice  several  normal  plates,  all  one  will  have 
to  do  will  be  to  look  on  the  card  of  this  particular  subject 
and  the  numbers  and  names  can  be  readily  obtained.  A 
list  of  the  cards  needed  (which  should  be  placed  in  the 
file  alphabetically)  is  here  given. 

1.  Accessory  Sinuses. 

2.  Cardiovascular  System. 

3.  Carpals. 

4.  Clavicle. 

5.  Femur. 

6.  Fibula. 

7.  Foreign  Bodies. 

8.  Gastrointestinal  Tract. 

9.  Head.    (This  takes  in  all  conditions 

of  the  head  with  the  exception  of 
foreign  bodies  and  accessory 
sinuses.) 

10.  Humerus. 

11.  Ilium. 

12.  Ischium. 

13.  Metacarpals. 
13.  Metatarsals. 

15.  Miscellaneous. 

16.  Os  pubis. 

17.  Patella. 

18.  Phalanges  (lower  extremity). 

19.  Phalanges  (upper  extremity). 

20.  Radius. 

21.  Respiratory  Tract. 

22.  Ribs. 

23.  Scapula. 

24.  Sternum. 


134  ROENTGEN  TECHNIC 

25.  Tarsals. 

26.  Tibia. 

27.  Ulna. 

28.  Urinary  Tract. 

29.  Vertebra. 

If  preferred  a  small  loose  leaf  book  can  be  used,  add- 
ing to  it  as  the  cases  come  in,  having  several  pages  re- 
served for  each  heading. 

Convenient  floor  plans  for  the  arrangement  of  the  of- 
fice are  shown  in  Figs.  66,  67,  68,  69,  70,  and  71. 


DARK    ROOM    PROCEDURES 


135 


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136 


ROENTGEIST   TECHNIC 


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DARK    ROOM    PROCEDURES 


137 


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Fig.   71. — Floor  plan  No.  6. 


GENERAL  INDEX 


Ankle,   position,  44 
Antral  position,  78 
Appendix,  examination  of,  98 
Avoirdupois,  weights,  111 


Barium  sulphate,  dose  of,  90 
Bath,  fixing,  113 
Bismuth  salts,  dose  of,  90 
Bladder,  contrast  solution  for,  71 

diverticula    of,    71 

gall,   position,  86 

positions,  72 
Board,  ferrotype,  119 

squeegee,  119 
Bodies,  foreign,  localization,  104 


Cap,  Bishop's,  91 

Chest,  examination  of,  74 

positions,   76 
Circuit,   electrical,  23 
Clavicle  position,  62 
Cramer's   plates,   116 
Cross    index,    132 
Current,  high  tension,  23 

low  tension,   23 

D 

Dark   room,   107 

color  of,   108 

cooling,  115 

heating,   115 

shelves  in,  107 

size  of,  107 

storage  in,  107 

ventilation  of,  109 
Developer,  temperature  of,  114 
Developers,   printing,   118 
Developing,  114 

formulae,   111 

lantern   slides,   127 
Diagnostic   plates,   39 
Diverticula,  locating,  71 
Dodging,  119 
Drying,  prints,  119 
Duodenal  cap,  91 
Duodenal  positions,  92 


E 

Elbow  positions,  42 
Enema,  contrast,  99 
Esophagus,  examination  of,  88 

mixture    used    for    examination 
of,  88 

position,  88 
Ethmoid,  sinuses,  78 

F 

Ferrotype  board,  119 
Fixing  bath,  113 
Foot  positions,  46 
Foreign    bodies,    geometrically   lo- 
cated, 105 
localization,  105 
Formulae,   developing,   111 
Frontal  sinuses,  78 

G 

Gall  bladder,  positions,  86 
Gap,  spark,  23 

Gastrointestinal  tract,  examination 
of,  90 

H 

Hand  positions;  40 
Head  positions,  78 
Hip  positions,  50 


Index,  cross,   132 

Intestinal  tract,  examination  of,  90 


Jaw,  lower,  position,  82 

K 

Kidney,  position,  72 
Kuegle   technic,    100 


Lantern  slides,  121 

making  of,  119 

size  of,  121 
Loading  plates,  110 
Localization  of  foreign  bodies,  104 


139 


140 


CKXKRAL    INDEX 


M 

Mandible    position,   82 
Mastoid  position,  81 
Milliammeter,  21 
Milliampere,  21 
Mixtures,  opaque,  90 

N 

Xeck  positions,  56 
Negatives,  127 

O 

Opaque  mixtures,  90 


Paper,    printing,    118 
Paragon  plates,   115 
Patient,  preparation  of,  31 
Pelvis,  positions,  52 
Plate,  changers,  37 

composition  of,  19 

dry,  19 

loading,  110 

sensitized,  19 

storage  of,  131 
Plates,  Cramer's,  116 

diagnostic,   39 

paragon,   115 

peculiarities  of,   115 

Seed's,  116 

speed  of,  39 
Positions,  127 
Printing,  117 

developer  for,  118 

papers,  118 
Prints,  luster  in,   119 
Pyloroentgenography,    70 

E 

Eib   positions,   67 
Room,   dark,   107 


S 

Scapula  position,  64 
Screen,  fluorescent,  18 

intensifying,  20 
Seed's  plates,  116 
Serial  roentgenography,  94 

apparatus  for,   94 
Shoulder  position,  54 
Sinuses,  injection  of,   103 

positions,  78 
Slides,   lantern,   121 
Solutions,  temperature  of,  114 
Sphenoid   sinuses,    78 
Spine,  dorsal  position,  58 

lumbar  position,  60 
Squeegee  board,  19 
Stereoscopy,  34 
Sternum  position,  66 
Stomach,   examination   of,  90 

positions,  92 
Storage  of  plates,  138 

T 

Tank,  developing,   108 
Teeth  positions,  84 
Tube,  classes,  24 

Coolidge,  25 

gas,   24 

reducing,   28 
Tubes,  principle  of,  24 
Transformer,  step  down,  26 

U 

Ureter  position,  72 
Urinary  tract  position,  68 

W 

Weights,  avoirdupois,  111 

photographic,  41 
Wrist  positions,  40 


X-rays,   intensity   of,  26 
production   of,    21 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 

Los  Angeles 
This  book  is  DUE  on  the  last  date  stamped  below. 


Form  L9-42m-8, '49(85573)444 


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A     000  383  857    o 


